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Front Cover.
Disclaimer
The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the National Cancer Institute of the National
Institutes of Health, an agency of the U.S. Department of Health and Human Services, or the World
Health Organization concerning the legal status of any country, territory, city, or area, or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on
maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the National Cancer Institute or the World Health Organization in
preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names
of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the National Cancer Institute and the World Health
Organization to verify the information contained in this publication. However, the published material is
being distributed without warranty of any kind, either expressed or implied. The responsibility for the
interpretation and use of the material lies with the reader. In no event shall the National Cancer Institute
or World Health Organization be liable for damages arising from its use. The named authors alone are
responsible for the views expressed in this publication.
NCI Tobacco Control Monographs
To cite this monograph in other works, please use the following format:
U.S. National Cancer Institute and World Health Organization. The Economics of
Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph
21. NIH Publication No. 16-CA-8029A. Bethesda, MD: U.S. Department of Health and
Human Services, National Institutes of Health, National Cancer Institute; and Geneva,
CH: World Health Organization; 2016.
This monograph and its supplemental materials may be found electronically at http://cancercontrol.cancer.gov/brp/tcrb/monographs/21/index.html.
All NCI Tobacco Control Monographs are available from the Web page http://cancercontrol.cancer.gov/brp/tcrb/monographs.
Recently Published Monographs
Phenotypes and Endophenotypes: Foundations for Genetic Studies of Nicotine Use and Dependence.
Tobacco Control Monograph No. 20. NIH Publication No. 09-6366, August 2009.
The Role of the Media in Promoting and Reducing Tobacco Use. Tobacco Control Monograph No. 19.
NIH Publication No. 07-6242, August 2008.
Greater than the Sum: Systems Thinking in Tobacco Control. Tobacco Control Monograph No. 18. NIH
Publication No. 06-6085, May 2007.
Evaluating ASSIST: A Blueprint for Understanding State-level Tobacco Control. Tobacco Control
Monograph No. 17. NIH Publication No. 06-6058, October 2006.
Monograph 21: The Economics of Tobacco and Tobacco Control
3
Acknowledgments
This monograph and executive summary were developed by the National Cancer Institute and the World
Health Organization. The monograph is the culmination of efforts of more than 60 authors, who are
listed below along with the monograph’s editors and editorial teams. The monograph went through an
extensive peer-review process involving more than 70 reviewers, who are acknowledged in the full
monograph.
Scientific Editors
Frank J. Chaloupka, Ph.D.
Distinguished Professor
Department of Economics
Director
Health Policy Center
Institute for Health Research and Policy
University of Illinois at Chicago
Chicago, Illinois, United States
Geoffrey T. Fong, Ph.D.
Professor
Department of Psychology
University of Waterloo
Canada Senior Investigator
Ontario Institute for Cancer Research
Toronto, Ontario, Canada
Ayda Aysun Yürekli, Ph.D.
Visiting Senior Research Scientist
Institute for Health Research and Policy
University of Chicago at Illinois
Chicago, Illinois, United States
Contributing Authors
Arnab Acharya, Ph.D.
Public Health Policy Senior Lecturer
London School of Hygiene and Tropical Medicine
London, England, United Kingdom
Kathryn Angus, Ph.D.
Research Officer
Institute for Social Marketing
University of Stirling
Stirling, Scotland, United Kingdom
Samira Asma, D.D.S., M.P.H.
Chief
Global Noncommunicable Diseases Branch
Division of Global Health Protection
Center for Global Health
Centers for Disease Control and Prevention
Atlanta, Georgia, United States
Douglas W. Bettcher, M.D., Ph.D., M.P.H.
Director
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Kenneth Blackman, Ph.D.
Statistician
Econometrica, Inc.
Bethesda, Maryland, United States
Evan Blecher, Ph.D.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Ron Borland, Ph.D., M.A.P.S.
Nigel Gray Distinguished Fellow in Cancer Prevention
Cancer Council Victoria
Melbourne, Victoria, Australia
Christina Ciecierski, Ph.D.
Associate Professor of Economics
College of Arts and Sciences
Northeastern Illinois University
Chicago, Illinois, United States
A’isha Alison Commar, M.A.
Technical Officer
Comprehensive Information Systems for Tobacco Control
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Meishan Cui
Intern, Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Vera Luiza da Costa e Silva, M.D., Ph.D., M.B.A.
Head of the Convention Secretariat
WHO Framework Convention on Tobacco Control
World Health Organization
Geneva, Switzerland
Acknowledgments
4
Annette M. David, M.D., M.P.H.
Adjunct Research Faculty
Cancer Research Center
University of Guam
Mangilao, Guam
Clinical Associate Professor
Cancer Research Center of Hawaii
University of Hawaii at Manoa
Honolulu, Hawaii, United States
Sofia Delipalla, Ph.D.
Professor
Department of Balkan, Slavic and Oriental Studies
School of Economic and Regional Studies
University of Macedonia
Thessaloniki, Greece
Sherry Emery, Ph.D., M.B.A.
Senior Fellow of Public Health
National Opinion Research Center
University of Chicago
Chicago, Illinois, United States
Dongbo Fu, M.D., Ph.D., M.P.H.
Technical Officer, National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
C.K. Gajalakshmi
Director
Epidemiological Research Center
Tamil Nadu, India
Vendhan Gajalakshmi, Ph.D. Epidemiological Research Center
Tamil Nadu, India
Mark Goodchild, B.Bus.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Emmanuel Guindon, Ph.D.
Assistant Professor
Department of Clinical Epidemiology and Biostatistics
McMaster University
Hamilton, Ontario, Canada
Prakash Gupta, D.Sc., F.A.C.E.
Director
Healis–Sekhsaria Institute for Public Health
Mumbai, India
Reviva Hasson, M.Com.
Research Fellow
Environmental-Economics Policy Research Unit
School of Economics
University of Cape Town
Cape Town, South Africa
Gerard Hastings, Ph.D.
Emeritus Professor
Centre for Tobacco Control Research
Institute for Social Marketing
University of Stirling
Stirling, Scotland, United Kingdom
Luminita S. Hayes, M.D., P.H.Sp., M.Sc.
Medical Officer, National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Sara Hitchman, Ph.D., M.A.Sc.
Lecturer in Addictions
Addictions Department
King’s College London
London, England, United Kingdom
Kinh Hoang-Van
Professor
Department of Economics
University of Commerce
Hanoi, Vietnam
Jidong Huang, Ph.D.
Associate Professor
Health Management and Policy
School of Public Health
Georgia State University
Atlanta, Georgia, United States
Andrew Hyland, Ph.D.
Chair
Division of Cancer Prevention and Population Sciences
Department of Health Behavior
Roswell Park Cancer Institute
Buffalo, New York, United States
Nathan Jones, Ph.D.
Senior Project Director
University of Wisconsin Survey Center
University of Wisconsin–Madison
Madison, Wisconsin, United States
John Keyser
Senior Agriculture Trade Economist
Trade and Competitiveness Global Practice
World Bank Group
Lusaka, Zambia
Monograph 21: The Economics of Tobacco and Tobacco Control
5
Pierre Kopp, Ph.D.
Professor
Panthéon-Sorbonne University
Paris, France
Harry Lando, Ph.D.
Professor
Division of Epidemiology and Community Health
University of Minnesota
Minneapolis, Minnesota, United States
David Levy, Ph.D.
Professor of Oncology
Lombardi Comprehensive Cancer Center
Georgetown University
Washington, D.C., United States
James Lightwood, Ph.D.
Associate Professor
Department of Clinical Pharmacy
School of Pharmacy
University of California, San Francisco
San Francisco, California, United States
Christine Logel, Ph.D.
Associate Professor
Renison University College
University of Waterloo
Waterloo, Ontario, Canada
Benn McGrady, Ph.D.
Technical Officer (Legal), National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Yumiko Mochizuki-Kobayashi, M.D., Ph.D.
Researcher
Tobacco Policy Research
Center for Cancer Control and Information Services
National Cancer Center
Tokyo, Japan
Mario Monsour, M.A., M.B.A.
Deputy Chief
Tax Policy Division
International Monetary Fund
Washington, D.C., United States
Nigar Nargis, Ph.D.
Formerly Economist, World Health Organization
Currently Director, Economic and Health Policy Research
Program
American Cancer Society
Washington, D.C., United States
Richard J. O’Connor, Ph.D.
Professor of Oncology
Division of Cancer Prevention and Population Sciences
Department of Health Behavior
Roswell Park Cancer Institute
Buffalo, New York, United States
Maizurah Omar, Ph.D.
Associate Professor
National Poison Centre
Universiti Sains Malaysia
Penang, Malaysia
Zeynep Önder, Ph.D.
Associate Professor
Faculty of Business Administration
Bilkent University
Ankara, Turkey
William Onzivu, Ph.D., L.L.M.
Project Officer
Noncommunicable Disease Cluster
World Health Organization Regional Office for Africa
Brazzaville, Congo, and Kampala, Uganda
Anne-Marie Perucic, M.Sc.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Armando Peruga, M.D., Ph.D., M.P.H.
Formerly Programme Manager, World Health
Organization
Currently Scientist, Center of Epidemiology and Health
Policy
School of Medicine
Universidad del Desarrollo
Santiago, Chile
Vinayak M. Prasad, M.D.
Programme Manager
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Martin Raw, Ph.D.
Director
International Centre for Tobacco Cessation
University of Nottingham
Nottingham, England, United Kingdom
Cecily S. Ray, M.P.H.
Senior Research Assistant
Epidemiology and Public Health Department
Healis–Sekhsaria Institute for Public Health
Mumbai, India
Acknowledgments
6
Lyn Reed, Ph.D.
Economic Consultant
International Trade and Development
Cape Town, South Africa
Bung-on Ritthiphakdee
Director
Southeast Asia Tobacco Control Alliance
Bangkok, Thailand
Hana Ross, Ph.D.
Principle Research Officer and SALDRU Affiliate
South African Labour and Development Research Unit
School of Economics
University of Cape Town
Cape Town, South Africa
Jennifer Ruger, Ph.D., M.Sc.
Professor of Health Equity, Economics, and Policy
School of Social Policy and Practice
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania, United States
Henry Saffer, Ph.D.
Research Associate
Health Economics Program
National Bureau of Economics Research
New York, New York, United States
Genevieve Sansone, Ph.D.
Research Associate
International Tobacco Control Policy Evaluation Project
University of Waterloo
Waterloo, Ontario, Canada
Natalie Sansone, Ph.D.
Consulting Analyst, Research
Info-Tech Research Group
London, Ontario, Canada
Fatwa Sari Tetra Dewi, Ph.D., M.P.H.
Assistant Professor
Medical Practitioners Department
Universitas Gadjah Mada
Yogyakarta, Indonesia
Kerstin Schotte, M.D., M.P.H.
Technical Officer
Comprehensive Information Systems for Tobacco Control
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Omar Shafey, Ph.D., M.P.H.
Senior Officer
Medical Research Public Health and Policy
Health Authority
Abu Dhabi, United Arab Emirates
Yoon-Jeong Shin, Ph.D.
Research Fellow
Population Strategy Research Division
Center for Policy on Low Fertility
Korea Institute for Health and Social Affairs
Sejong City, Republic of Korea
Giorgio Sincovich
Senior Intellectual Property Crime Expert
Operational Department – Economic Crime
Europol
The Hague, Netherlands
John Tauras, Ph.D.
Associate Professor
Department of Economics
College of Liberal Arts and Sciences
University of Illinois at Chicago
Chicago, Illinois, United States
Mark Travers, Ph.D., M.S.
Research Scientist
Division of Cancer Prevention and Population Sciences
Department of Health Behavior
Roswell Park Cancer Institute
Buffalo, New York, United States
Édouard Tursan d’Espaignet, Ph.D.
Coordinator
Comprehensive Information Systems for Tobacco Control
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Marco Vargas, Ph.D.
Assistant Professor
Department of Economics
Fluminense Federal University
Niteroi, Brazil
Mandeep K. Virk-Baker, Ph.D., M.S., M.P.H., R.D.
Cancer Prevention Fellow
Health Behaviors Research Branch
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Monograph 21: The Economics of Tobacco and Tobacco Control
7
Corné van Walbeek, Ph.D.
Professor
School of Economics
University of Cape Town
Cape Town, South Africa
Charles W. Warren, Ph.D.
Distinguished Fellow and Statistician-Demographer
Global Immunization Division
Global Health
Centers for Disease Control and Prevention
Atlanta, Georgia, United States
Marzenna Anna Weresa
Director and Professor
World Economy Research Institute
Collegium of World Economy
Warsaw School of Economics
Warsaw, Poland
Xin Xu, Ph.D.
Senior Economist
Office on Smoking and Health
National Center for Chronic Disease Prevention and
Health Promotion
Centers for Disease Control and Prevention
Atlanta, Georgia, United States
Eduard Zaloshnja, Ph.D.
Research Scientist
Pacific Institute for Research and Evaluation
Calverton, Maryland, United States
Lei Zhang, Ph.D., M.B.A., M.S.D.H.
Health Scientist
Office on Smoking and Health
National Center for Chronic Disease Prevention and
Health Promotion
Centers for Disease Control and Prevention
Atlanta, Georgia, United States
Ping Zhang, Ph.D.
Health Economist
Office on Smoking and Health
National Center for Chronic Disease Prevention and
Health Promotion
Centers for Disease Control and Prevention
Atlanta, Georgia, United States
NCI Editorial Team
Rachel Grana Mayne, Ph.D., M.P.H.
Program Director
Tobacco Control Research Branch
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Yvonne Hunt, Ph.D., M.P.H.
Program Director
Tobacco Control Research Branch
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Stephen Marcus, Ph.D.
Program Director
Division of Biomedical Technology, Bioinformatics, and
Computational Biology
National Institute of General Medical Sciences
National Institutes of Health
Bethesda, Maryland, United States
Mark Parascandola, Ph.D., M.P.H.
Epidemiologist
Tobacco Control Research Branch
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Jerry Suls, Ph.D.
Senior Scientist
Office of the Associate Director
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Michele Bloch, M.D., Ph.D.
Chief
Tobacco Control Research Branch
Behavioral Research Program
Division of Cancer Control and Population Sciences
National Cancer Institute
National Institutes of Health
Bethesda, Maryland, United States
Acknowledgments
8
WHO Editorial Team
Zahra Ali Piazza
World Health Organization, Headquarters
Geneva, Switzerland
Douglas W. Bettcher, M.D., Ph.D., M.P.H.
Director
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Evan Blecher, Ph.D.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
A’isha Alison Commar, M.A.
Technical Officer
Comprehensive Information Systems for Tobacco Control
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Elizabeth de Guia Tecson, B.Sc.
Administrative Assistant, Director’s Office
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Dongbo Fu, M.D., Ph.D., M.P.H.
Technical Officer, National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Mark Goodchild, B.Bus.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Luminita S. Hayes, M.D., P.H.Sp., M.Sc.
Medical Officer, National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Luis Enrique Madge Rojas
Secretary, Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Benn McGrady, Ph.D.
Technical Officer (Legal), National Capacity
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Nigar Nargis, Ph.D.
Formerly Economist, World Health Organization
Currently Director, Economic and Health Policy Research
Program
American Cancer Society
Washington, D.C., United States
Jeremias N. Paul, Jr., M.S.I.E., M.I.A.
Coordinator, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Anne-Marie Perucic, M.Sc.
Economist, Tobacco Control Economics
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Armando Peruga, M.D., Ph.D., M.P.H.
Formerly Programme Manager, World Health
Organization
Currently Scientist, Center of Epidemiology and Health
Policy
School of Medicine
Universidad del Desarrollo
Santiago, Chile
Vinayak M. Prasad, M.D.
Project Manager
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Kerstin Schotte, M.D., M.P.H.
Technical Officer
Comprehensive Information Systems for Tobacco Control
Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Édouard Tursan d’Espaignet, Ph.D.
Coordinator
Comprehensive Information Systems for Tobacco Control
Tobacco Free Initiative
World Health Organization, Headquarters
Geneva, Switzerland
Emily Wymer, B.A. (Hons) (Cantab)
Consultant, Prevention of Noncommunicable Diseases
World Health Organization, Headquarters
Geneva, Switzerland
Monograph 21: The Economics of Tobacco and Tobacco Control
9
BLH Technologies, Inc. Team (By contract to the National Cancer Institute)
Lisa Adams
Dana Chomenko, M.A., PMP
Ruth Clark
Kathryn Cleffi, M.P.H.
Pamela Grimes
Amanda Huffman, M.P.H.
James Libbey, M.P.I.A.
Marcia McCann, M.S.W.
Jenny Twesten, M.P.H.
With additional thanks to:
Shabana Abdullah, M.S.W.
Julie Bromberg, M.H.S., CHES
Kelly Burkett, M.P.H., PMP
Krystal Lynch, Ph.D., M.P.H.
Steve McLaine, M.P.P.
Jennifer Schindler-Ruwisch, M.P.H., CPH
American Institutes for Research Team (By contract to the National Cancer Institute)Allan Clyde Margo Edmunds Anne Horton Bethany Meissner Margot Raphael Rich Yelle
Executive Summary
10
This Executive Summary is a synopsis of The Economics of Tobacco and Tobacco Control. It describes the monograph’s purpose and organization, provides an overview of the major volume and chapter-level conclusions, and discusses research needs for each topic area. Readers are encouraged to access the full report for an in-depth synthesis of scientific evidence on the economics of global tobacco and tobacco control. Readers can find the supporting references and other documentation in the full report.
Introduction
Tobacco use remains one of the world’s leading causes of preventable premature death. Today it is also
a global public health issue which is increasingly seen in economic and geopolitical terms as well as in
social, cultural, and biomedical contexts. These factors have played key roles in the current policy
interventions for tobacco control worldwide, most notably the World Health Organization (WHO)
Framework Convention for Tobacco Control (WHO FCTC).1
This monograph is the 21st volume in the series of monographs on tobacco control produced by the
National Cancer Institute (NCI) of the National Institutes of Health, an agency of the U.S. Department
of Health and Human Services. This monograph examines the economics of global tobacco control and
features the contributions of many leading researchers in the field. It examines the current research and
evidence base surrounding the economics of tobacco control—including tobacco use, tobacco growing,
manufacturing and trade, tobacco product taxes and prices, and tobacco control policies and other
interventions to reduce tobacco use and its consequences—and the economic implications of global
tobacco control efforts.
This report follows in the steps of a growing literature base on global economic issues in tobacco
control. As early as 1992, the U.S. Surgeon General’s report Smoking and Health in the Americas2
included a chapter reviewing international data on the economic costs of smoking, the economics of
growing and manufacturing, and the impact of tobacco taxes. This was followed by the 1999 World
Bank publication Curbing the Epidemic: Governments and the Economics of Tobacco Control3 and the
companion volume, Tobacco Control in Developing Countries,4 which contained the background papers
produced for the World Bank report.
Why is a global economics of tobacco and tobacco control monograph needed today? There are several
reasons, including:
Extensive new evidence from low- and middle-income countries (LMICs), much of it derived
from research supported by international agencies
New questions raised by emerging political, supply-side, and health concerns
New infrastructure issues ranging from privatization to trade liberalization
New global economic concerns about tobacco use and tobacco control.
As the study of the production, distribution, and consumption of goods and services, economics has
become integral to understanding and addressing tobacco use. The history of tobacco control has its
origins in direct interventions for tobacco use, such as public education and efforts to promote smoking
cessation. In the 21st century, however, it is increasingly recognized that the economic and consumer
Monograph 21: The Economics of Tobacco and Tobacco Control
11
behavioral factors common to all goods are intimately involved in the process of making further
reductions in global tobacco use.
Knowledge from specific subdisciplines of economics has led to new ways of controlling the use of
addictive consumer goods such as tobacco. As examples: public finance theory has increased
understanding of the powerful influence of excise taxation, and the mix of specific and ad valorem
taxation; the economics of regulation supports arguments for government intervention in tobacco
markets; health economics reveals how tobacco demand and cost modeling can drive policy change;
labor economics helps address the employment impact of effective tobacco control policies; and
consumer behavioral theories such as the rational choice model of addiction help us understand how
pricing and other correlates such as warning labels and product attributes influence consumption. At
a global level, international trade principles provide insight into the mechanics of licit and illicit trade
in cigarettes.
Specific chapters of the monograph examine these and other areas in detail, aided by global data
sources compiled by various stakeholders, such as WHO, the World Bank, the United Nations Food
and Agriculture Organization, the Centers for Disease Control and Prevention (an agency of the
U.S. Department of Health and Human Services), private organizations, and others.
WHO FCTC: A Framework for Action
A milestone in the implementation of evidence-based tobacco control interventions has been the entry
into force of the legally binding WHO FCTC,1 which provides a set of actions to reduce demand for, and
supply of, tobacco products. The WHO FCTC, which was negotiated between 1999 and 20031 and
entered into force as international law in February 2005,5 is an extraordinary public health tool. It is a
trend-setting instrument in global, regional, and national tobacco control which has changed the
paradigm of health promotion policies. As of November 2015, 179 countries and the European Union
were Parties to the WHO FCTC.
The WHO FCTC represents the culmination of years of collaborative, multidisciplinary engagement by
governments, elements of civil society, and international organizations to address the tobacco epidemic
using international law. It offers a comprehensive set of affordable, evidence-based tobacco control
measures that involve many sectors of society and operate in both the demand-reduction and supply-
restriction areas. An international instrument for tobacco control policy interventions, the WHO FCTC
reflects the gravity of the worldwide tobacco epidemic, the relative weakness of domestic regulatory
agencies in most WHO Member States, and the economically driven spread of tobacco marketing
strategies at the country level.6,7
It also reflects the collaboration needed among countries to counteract
the globalization of tobacco industry promotional practices with cross-border effects. The transnational
nature of the tobacco trade, including trade liberalization and foreign direct investment, tobacco
marketing, and the flow of contraband, also points to the need for international regulatory strategies.
Ultimately, the WHO FCTC aims to strengthen tobacco control efforts at the country level by, among
other things, facilitating ongoing information-sharing and technical assistance and by creating an
international framework through which nations can address the supranational dimensions of tobacco
control. A key goal of the monograph is to present the research base for countries implementing the
WHO FCTC—to fill the information gap on policy-relevant issues, provide comprehensive global and
Executive Summary
12
country-level evidence on the economics of tobacco control, and disseminate information that helps
countries build their own tobacco control infrastructure relative to the WHO FCTC.
Preparation of The Monograph
The NCI, in conjunction with WHO, invited three experts representing the domains of economics,
public health, and tobacco control to serve as the editors of the monograph. This ambitious effort
included contributions from more than 60 authors selected for their individual and collective expertise.
These authors are based or work in all major world regions, with an emphasis on LMICs, which have
traditionally been underrepresented in tobacco control economics research.
The monograph was subjected to a rigorous review process, which began with a review of the
monograph outline. As each chapter was drafted, the chapter was reviewed by many peer reviewers with
expertise on the individual topic. When the entire volume was complete, the full draft was submitted to
expert reviewers who evaluated the monograph as a whole, related one chapter to another, and ensured
that the volume-level conclusions were supported by the monograph’s content. Both NCI and WHO
conducted a final review before the monograph was published. Comments from more than 70 expert
reviewers formed the basis of the revisions that the authors and editors made to the monograph. These
efforts have culminated in a monograph comprising 17 chapters that explore the many dimensions of the
economics of tobacco and tobacco control, which are summarized and illustrated by numerous
examples, tables, and figures.
Where appropriate, the data for the monograph have been analyzed and reported by geographical area.
Countries are organized into WHO Regions: the African, Americas, South-East Asia, Eastern
Mediterranean, European, and Western Pacific Regions. The data are also presented using the World
Bank’s analytical classification of countries based on gross national income per capita: high-income,
upper middle-income, lower middle-income, and low-income countries.8 These classifications are
updated each year, thus the country income groups across the monograph are based on the year that best
reflects the data referenced.
Major Accomplishments
The volume accomplishes several “firsts.”
It examines the economics of tobacco control through the lens of the rapidly emerging body of
research that explores the impact of tobacco control in LMICs as well as the continually growing
research evidence from high-income countries (HICs). Although much of the new evidence from
LMICs corroborates the findings from work in HICs, much has been learned about the unique
challenges of implementing tobacco control in LMICs and many other areas where such efforts
have a potentially greater impact on economic and public health outcomes.
The monograph is one of the first publications to examine global tobacco control efforts since
the 2003 adoption and 2005 entry into force of the WHO FCTC, including the observed or
projected impact of specific articles of this global public health treaty and the subsequent
implementation assistance provided by the WHO MPOWER package.9
The monograph presents a growing base of data on tobacco control interventions and their
impact—data that were derived from public and private sources and from local and global
tobacco surveillance systems. Since the publication of Curbing the Epidemic: Governments and
Monograph 21: The Economics of Tobacco and Tobacco Control
13
the Economics of Tobacco Control, a considerable amount of new knowledge has been generated
using these data regarding the effectiveness of specific interventions and their relative impact on
the economies of countries at varying income levels.
Above all, the monograph confirms that effective, evidence-based tobacco control
interventions—such as increased taxes; complete bans on tobacco marketing; comprehensive,
smoke-free policies; dissemination of information on the health consequences of tobacco use;
and many other types of interventions—make sense from an economic as well as a public health
standpoint.
Major Conclusions
Nine broad conclusions that emerge from the volume are as follows:
1. The global health and economic burden of tobacco use is enormous and is increasingly
borne by low- and middle-income countries. Already, around 80% of smokers live in LMICs.
While smoking prevalence is falling at the global level, the total number of smokers worldwide
is not decreasing, largely due to population growth. There is a strong possibility that the global
target of a 30% relative reduction in tobacco use by 2025 agreed to by WHO Member States will
not be met. The number of tobacco-related deaths is projected to increase from about 6 million
deaths annually to about 8 million annually by 2030, with more than 80% of these occurring in
LMICs.
2. Failures in the markets for tobacco products provide an economic rationale for
governments to intervene in these markets. These market failures include (1) the public’s
imperfect and asymmetric information about the health and economic consequences of
consuming tobacco products, particularly in LMICs, which is further complicated by the time-
inconsistency of individual preferences for tobacco and the uptake of tobacco use during youth
and adolescence; and (2) the externalities of tobacco use for nonusers. These externalities include
the fact that nonsmokers, both children and adults, experience adverse health consequences when
exposed to secondhand smoke (SHS) and that the cost of treating diseases caused by tobacco use
and SHS exposure is borne, in part, by the public. The external costs of tobacco use are greater in
countries where public funds are used to pay for a greater share of health care costs, given public
spending to treat the diseases caused by tobacco use.
3. Effective policy and programmatic interventions are available to reduce the demand for
tobacco products and the death, disease, and economic costs that result from their use, but
these interventions are underutilized. The WHO FCTC and its implementation guidelines
provide an evidence-based framework for governmental action to reduce tobacco use. Technical
resources included in the MPOWER package in line with the WHO FCTC can support the
implementation of tobacco control demand-reduction provisions on the ground. In addition,
numerous other documents—including U.S. Surgeon General’s reports, NCI monographs, and
reports of the Institute of Medicine (U.S.), the WHO Tobacco Free Initiative, and the WHO
International Agency for Research on Cancer—summarize the science and provide guidance on
effective policy and program interventions. However, the vast majority of the world’s population
is still not adequately covered by the most effective of these interventions, including sufficiently
high levels of tobacco taxation, comprehensive smoke-free policies, complete bans on tobacco
marketing, information interventions, and cessation support.
Executive Summary
14
4. Policies and programs that work to reduce the demand for tobacco products are highly
cost-effective. Significant tobacco tax and price increases, comprehensive bans on tobacco
industry marketing activities, and prominent pictorial health warning labels are generally the
least costly tobacco control interventions, followed by the implementation and enforcement of
smoke-free policies and the provision of population-wide tobacco cessation programs.
Significant tobacco tax and price increases are the most cost-effective of these interventions.
Despite the considerable revenues generated by tobacco taxes, few governments are investing
more than a fraction of these revenues in tobacco control or in other health programs. WHO
estimated that in 2013–2014, global tobacco excise taxes generated nearly 269 billion U.S.
dollars (US$) in government revenues, but governments spent a combined total of less than
US$ 1 billion on tobacco control.10
5. Control of illicit trade in tobacco products, now the subject of its own international treaty,
is the key supply-side policy to reduce tobacco use and its health and economic
consequences. There is broad agreement that control of illicit trade will benefit tobacco control
and public health and result in broader benefits for governments. Other supply-side policies, such
as support for economically viable alternatives to tobacco production and restrictions on youth
access to tobacco products, can be effective, especially as part of a comprehensive strategy to
reduce tobacco use.
6. The market power of tobacco companies has increased in recent years, creating new
challenges for tobacco control efforts. The global tobacco market has become increasingly
concentrated over the past 25 years and is being driven by the same forces that have contributed
to globalization in other industries, including reductions in barriers to trade and foreign direct
investment, privatization of state-owned tobacco enterprises, and a wave of mergers and
acquisitions. Policies aimed at limiting the market power of tobacco companies are largely
untested but hold promise for reducing tobacco use.
7. Tobacco control does not harm economies. The number of jobs that depend on tobacco has
been falling in most countries, largely thanks to technological innovations, the shift from state-
owned to private ownership of tobacco manufacturing, and globalization, which have facilitated
efficiencies in tobacco growing and manufacturing. For the vast majority of countries,
implementation of tobacco control measures will have only a modest impact on tobacco-related
employment, and will not lead to net job losses. For the few countries particularly dependent on
tobacco growing and tobacco leaf exports, job losses due to global tobacco control efforts are
likely to be gradual, predictable, and far enough in the future to have little effect on the current
generation of tobacco farmers, and programs could be implemented that help tobacco farmers
make the transition to alternative livelihoods. Evidence from high-income countries and LMICs
shows that smoke-free policies do not adversely affect the hospitality sector.
8. Tobacco control reduces the disproportionate burden that tobacco use imposes on the poor.
Tobacco use is concentrated among the poor and other vulnerable groups, and tobacco use
accounts for a significant share of the health disparities between the rich and poor. These
disparities are exacerbated by a lack of access to health care and the diversion of household
spending from other basic needs, such as food and shelter, to tobacco use. Moreover, tobacco use
contributes to poverty, as illnesses caused by tobacco lead to increased health care spending and
reduced income. Research indicates that tobacco control interventions lead to reductions in
tobacco use among all population groups. Additionally, significant increases in tax and price lead
to greater reductions in tobacco use among the poor than among the rich, and thus contribute to
reducing health disparities. Tobacco taxes also provide the opportunity to dedicate tax revenues
Monograph 21: The Economics of Tobacco and Tobacco Control
15
specifically to health programs that benefit the poor, thus increasing their ability to reduce health
disparities between population subgroups.
9. Progress is now being made in controlling the global tobacco epidemic, but concerted
efforts will be required to ensure that progress is maintained or accelerated. In most world
regions and country income groups, the prevalence of tobacco use is stagnant or falling. In HICs,
progress in tobacco control has been ongoing over several decades; in LMICs, progress has
generally been more recent and has sometimes been more rapid. Factors contributing to recent
progress include the galvanizing effort of the WHO FCTC, research documenting the health and
economic burden of tobacco use and evidence-based tobacco control interventions, the
contributions of private funders and civil societies in promoting tobacco control policies, and
broad recognition of the tobacco industry’s role in promoting tobacco use around the world.
Despite this progress, many threats remain, including increasing tobacco use in some world
regions and the potential for tobacco use to increase in regions that are still at an early stage of
the tobacco epidemic. Maintaining and increasing progress will require continued research and
surveillance of the epidemic and implementation of the evidence-based strategies set forth in the
WHO FCTC, as well as vigilant monitoring of the tobacco industry’s tactics and strategies to
undermine or subvert tobacco control efforts.
Chapter Summaries, Research Needs, and Conclusions
Chapter 1. Overview and Conclusions
Chapter 1 introduces the monograph, describes its framework, and explains how it was prepared and
organized. It also presents the volume’s major conclusions and the individual chapter conclusions.
Chapter 2. Patterns of Tobacco Use, Exposure, and Health Consequences
Overview
Tobacco products, both smoked and smokeless products, are used in a wide variety of forms around the
world, and the patterns of use and resulting health and economic burden vary across the globe. Effective
tobacco control policies and programs are aimed at reducing the demand for tobacco products and the
death, disease, and economic cost of their use. This chapter examines tobacco consumption and
prevalence, as well as the impact of tobacco use and secondhand smoke exposure on health and
mortality. Specific topics include:
Current patterns of tobacco use across world regions and in selected countries for smoked and
smokeless products
Exposure to secondhand smoke, the effects of this exposure on health, and the associated disease
burden
Health disparities related to tobacco use
The impact of tobacco use on noncommunicable diseases, communicable diseases, and mortality.
This chapter describes the extent of tobacco use among youths and adults globally by drawing on
national or subnational data available for various countries. The chapter also examines the health
consequences of tobacco use, including data that is used in planning and evaluating tobacco control
policy and program interventions in many countries.
Executive Summary
16
Chapter Summary
Around the world, the health burden of tobacco use is enormous. At present, about 6 million people die
each year from tobacco use; this figure is projected to grow to 8 million by 2030, with the vast majority
(80%) of deaths anticipated to occur in LMICs. A wide variety of tobacco products—both smoked
products (cigarettes, cigars, kreteks, bidis, and waterpipe) and a diverse group of smokeless tobacco
products—are in use worldwide. Manufactured cigarettes, however, account for 92.3% of tobacco sales
worldwide; thus they are responsible for the vast majority of tobacco-caused disease and death.
Secondhand smoke, a mixture of sidestream smoke from the burning tip of cigarettes or other smoked
tobacco products and mainstream smoke exhaled by the smoker, is a cause of disease and death in adults
and children. Tobacco use and secondhand smoke exposure are now recognized as important causes of
noncommunicable disease, communicable disease, and harm during pregnancy. Tobacco use is
estimated to cause 12% of deaths among persons aged 30 and over worldwide; this represents about
14% of deaths from noncommunicable diseases (such as cancer, cardiovascular disease, and lung
disease) and 5% of deaths from communicable diseases (such as tuberculosis and lower respiratory tract
infections). Additionally, tobacco use contributes to and exacerbates poverty, which itself contributes to
ill health.
About 21% of the world’s population age 15 and over (about 1.1 billion people) are current smokers—
about 35% of males and 6% of females. Tobacco is a highly addictive substance, and the vast majority
of users smoke on a daily basis. With the exception of the African and Eastern Mediterranean Regions,
smoking prevalence is declining in all world regions; about half of all smokers live in either the South-
East Asia or the Western Pacific Region. Smoking prevalence is also declining when viewed from a
country income group perspective (high-, middle-, and low-income). The fact that the number of adult
tobacco users worldwide is not declining is primarily attributable to population growth. About 7% of
youth ages 13–15 worldwide smoke cigarettes, including about 9% of boys and 4.5% of girls. In many
countries, particularly low-income countries and lower middle-income countries, women’s smoking
prevalence remains low, often because of socio-cultural and economic factors discouraging tobacco use
among women. As these barriers fall, continued efforts will be required to ensure that women’s tobacco
use does not rise.
The number of smokeless tobacco users worldwide is estimated at 346 million, most of whom (86%)
live in the South-East Asia Region. Approximately 4% of youth ages 13–15 worldwide use smokeless
tobacco; as with adults, most 13- to 15-year-old smokeless tobacco users live in the South-East Asia
Region. An estimated 600,000 deaths worldwide in 2004 (1% of global mortality) were attributed to
SHS exposure. Data from countries participating in the Global Adult Tobacco Survey show a wide range
of SHS exposure at home and at work for both men and women. Data from the Global Youth Tobacco
Survey also show that a substantial proportion of youth ages 13–15 years are exposed to SHS in the
home and in other locations.
Studies from a number of countries document a disproportionate burden of tobacco use and SHS
exposure among disadvantaged groups, which are defined by income, race/ethnicity, geography, and
other factors. In most countries, poor people are more likely to smoke than their more affluent
counterparts, which contributes to a disproportionate burden of disease and death among the poor. The
four-stage model of the cigarette epidemic, developed by Lopez and colleagues provides a useful
illustration of the stages of development of the tobacco epidemic. Implementation of strong tobacco
control measures can hasten countries’ progress through the stages of this model, resulting in lower
prevalence of tobacco use and a lower burden of disease.
Monograph 21: The Economics of Tobacco and Tobacco Control
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Research Needs
Ongoing surveillance of all forms of tobacco use is critical to understanding the tobacco epidemic and
its shifting global impact, including the burden of disease resulting from tobacco use. It is important that
surveillance systems monitor and adapt to changes in the tobacco product landscape. Information is
especially needed on patterns of use of non-cigarette tobacco products, for which data are more limited.
Although the body of evidence on the health effects of cigarette smoking is extensive, the long-term
health effects of other tobacco products, including use of waterpipe and smokeless tobacco, are not as
well understood. Finally, more information is also needed on the prevalence and patterns of electronic
nicotine delivery systems (ENDS) use, as well as the short- and long-term health effects of these
products, including the effect of ENDS aerosol exposure on nonusers.
Chapter Conclusions
1. There are about 1.1 billion smokers in the world, and about 4 in 5 smokers live in LMICs.
Nearly two-thirds of the world’s smokers live in 13 countries.
2. Substantial progress has been made in reducing tobacco smoking in most regions, especially in
HICs. Overall smoking prevalence is decreasing at the global level, but the total number of
smokers worldwide is still not declining, largely due to population growth. Unless stronger
action is taken, it is unlikely the world will reach the WHO Member States’ 30% global
reduction target by 2025.
3. Globally, more than 80% of the world’s smokers are men. Differences in prevalence between
male and female smokers are particularly high in the South-East Asia and Western Pacific
Regions and in LMICs.
4. Globalization and population migration are contributing to a changing tobacco landscape, and
non-traditional products are beginning to emerge within regions and populations where their use
had not previously been a concern.
5. An estimated 25 million youth currently smoke cigarettes. Although cigarette smoking rates are
higher among boys than girls, the difference in smoking rates between boys and girls is narrower
than that between men and women. Smoking rates among girls approach or even surpass rates
among women in all world regions.
6. Worldwide, an estimated 13 million youth and 346 million adults use smokeless tobacco
products. The large majority of smokeless tobacco users live in the WHO South-East Asia
Region. Smokeless tobacco use may be undercounted globally due to scarcity of data.
7. Secondhand smoke exposure remains a major problem. In most countries, an estimated
15%–50% of the population is exposed to secondhand smoke; in some countries secondhand
smoke exposure affects as much as 70% of the population.
8. Annually, around 6 million people die from diseases caused by tobacco use, including about
600,000 from secondhand smoke exposure. The burden of disease from tobacco is increasingly
concentrated in LMICs.
Executive Summary
18
Chapter 3. The Economic Costs of Tobacco Use, With a Focus on Low- and Middle-Income Countries
Overview
The costs of tobacco use include illness, disability, premature death, and forgone consumption and
investment. This chapter examines the estimation of the costs of tobacco use by:
Reviewing the economic framework for cost estimation of tobacco use
Examining cost estimates for individual LMICs by World Health Organization Region
Analyzing recent cost estimates for HICs in the Region of the Americas, European Region, and
Western Pacific Region
Offering recommendations for addressing current gaps in data and areas for further study.
Significant obstacles to calculating comprehensive estimates of the costs of tobacco use still exist in
many countries, particularly in LMICs, where markets in many economic sectors do not function well.
Estimates from HICs consistently show that considerable economic costs, for both health care and lost
productivity, result from tobacco use and from exposure to secondhand smoke among nonsmokers.
Where sufficient data exist, they demonstrate that tobacco-related health care costs for LMICs are
comparable to those for HICs when considered as a percentage of total health care costs.
Chapter Summary
Progress has been made during the past 15 years on estimating the costs of smoking. These estimates are
useful in documenting the economic burden of tobacco use, designing tobacco control programs, and
identifying the health care needs of vulnerable populations, and, where such studies exist, they have at
times motivated policymakers to implement strong tobacco control policies. Reliable cost estimates are
lacking for many countries, especially LMICs. Where sufficient data exist for these estimates, they show
that the direct cost of tobacco-related disease in LMICs is comparable to that in HICs—that is, the direct
health care cost of smoking is similar in terms of the percentage of total health care expenditures. The
indirect cost of mortality is also high, at least in countries for which such cost can be measured.
Substantial economic resources are lost to other uses because of tobacco-related illnesses, premature
disability, and death. These losses are especially harmful in LMICs, where economic resources are
urgently needed for economic and social investment.
In countries with underdeveloped formal health care and social insurance systems, the estimated costs of
smoking vary widely among studies, most likely because (a) the formal health care system is not fully
developed or is changing rapidly and (b) data on utilization and cost of treatment are incomplete or of
poor quality.
Similarly, the indirect cost of smoking may be much higher than measured in existing studies. Evidence
from household expenditure surveys in several LMICs and HICs shows that tobacco use displaces
household expenditures on education and medical care, which are important investments to improve
economic well-being. In countries with poorly developed social insurance sectors and large burdens of
poverty on households, other expenditures displaced by tobacco use may have very large long-term
costs.11
Many estimates of the cost of direct health care attributable to smoking have some limitations. For
example, cost estimates may be lacking for maternal tobacco use during pregnancy and for exposure to
secondhand smoke on perinatal, infant, child, and adult health. Estimates do not always cover the full
Monograph 21: The Economics of Tobacco and Tobacco Control
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range of tobacco-related diseases, especially in LMICs, where direct cost estimates focus on only the
most prominent diseases (e.g., lung cancer, chronic obstructive pulmonary disease, and ischemic heart
disease) linked to smoking. Furthermore, estimates do not always account for all of the health care costs
of tobacco use and often use attributable or relative risk estimates from other countries that may not be
applicable to the country under study. Finally, relatively few studies distinguish between internal and
external costs of tobacco use. External costs are of particular interest and can vary considerably across
countries given the differences in nonsmokers’ exposure to secondhand smoke and the extent of the
governments’ role in providing health care.
Research Needs
Many of the studies profiled in this chapter lack data in one or more of the following areas:
Epidemiological data on the incidence or prevalence of many tobacco-related diseases
Adjusted country-specific estimates of relative risk and attributable fractions of mortality, health
care costs, or disability due to tobacco use
Total utilization and expenditures for treatment, including disease-specific costs
Insurance, labor force participation, and earnings data that can provide market-based estimates of
the productivity costs of death and disability.
Several studies in this review illustrate approaches that can be used to remedy these problems.
Comprehensive estimates of the cost of smoking at the country, region, and global levels should be a
high priority. These estimates are important for documenting the economic burden of tobacco use,
designing effective tobacco control programs, and identifying the health care needs of vulnerable
populations. Even in countries where data are limited, estimates using the available data that can be done
at relatively low cost, such as those described in the WHO toolkit on assessing economic costs,12
can be
useful in advancing tobacco control efforts.
Chapter Conclusions
1. The economic costs of tobacco use are substantial and include significant health care costs for
treating the diseases caused by tobacco use and the lost productivity that results from tobacco-
attributable morbidity and mortality.
2. In high-income countries, lifetime health care costs are greater for smokers than for nonsmokers,
even after accounting for the shorter lives of smokers.
3. Evidence on the economic costs of tobacco use in low- and middle-income countries is limited
but growing; the comprehensiveness of these studies varies greatly within and across countries,
as do the existing cost estimates.
4. Past and current trends in tobacco use, together with improvements in health care systems and
access to health care, suggest that the economic costs of tobacco use in low- and middle-income
countries are likely to increase considerably in coming years.
5. The public’s share of tobacco-attributable economic costs varies significantly among countries,
reflecting differences in the role of government in providing health care.
Executive Summary
20
Chapter 4. The Impact of Tax and Price on the Demand for Tobacco Products
Overview
Tobacco taxes and prices are key factors in controlling the demand for tobacco products and essential
components of an integrated approach to tobacco control. This chapter examines the evidence
surrounding tobacco taxation and pricing and the impact of taxation and pricing on the prevalence of
tobacco use and the consumption of tobacco products. This chapter discusses:
Models of the demand for tobacco products, including economic models of addiction
The evidence on the impact of taxes and prices on the demand for tobacco products
The effect of factors such as age and gender on sensitivity to changes in the price of tobacco
products.
Taxes on tobacco products tend to be higher in HICs than in LMICs. Tobacco products are often more
affordable in HICs than in LMICs, but over time, cigarettes have generally become less affordable in
HICs and more affordable in LMICs. Significant tax and price increases can have a particularly strong
impact on some of the groups most affected by the tobacco epidemic, including youth and people in
LMICs.
Chapter Summary
Failures in the markets for tobacco products, including consumers’ imperfect information about the
health harms of tobacco use and the health and financial impacts of tobacco use, provide an economic
rationale for governments to reduce tobacco use through economic interventions such as higher taxes on
tobacco products and other tobacco control policies. Excise taxes on tobacco products are the most
direct policy for influencing cigarette and other tobacco product prices. The total tax burden on tobacco
products is defined as the sum of all taxes on the product expressed as a percentage of the retail price,
and there is a close correlation between the tax burden on tobacco and the price of tobacco products,
particularly in countries with a high tax burden. In general, the total tax burden on cigarettes is highest
in HICs.
The retail price of cigarettes is a key determinant of cigarette consumption, and changes in the retail
price induce changes in consumption. Tobacco consumption is also sensitive to changes in consumer
income—the more affordable a product, the more likely it is to be purchased. As with price, consumers
respond to changes in affordability. The affordability of cigarettes can be measured by either the number
of minutes of labor required to purchase a pack of cigarettes or the percentage of per capita gross
domestic product required to purchase 100 packs of cigarettes. In general, studies find that although
cigarette taxes and prices tend to be highest in HICs and lowest in LMICs, cigarettes tend to be more
affordable in HICs than in lower income countries. Since the 1990s, however, cigarettes have become
relatively less affordable in HICs and relatively more affordable in LMICs, which has contributed to
decreased consumption in HICs but increased consumption in LMICs.
Econometric studies of the impact of tax and price on tobacco use employ two primary measures of
tobacco use: (1) macro-level aggregate measures of consumption, such as country-level data on tobacco
sales (this literature developed earlier, growing rapidly before the 1990s); and (2) household or
individual-level data taken from surveys, such as national surveys of drug use or health risk behavior.
Over time, a substantial body of evidence has accumulated that demonstrates that higher taxes and prices
lead to reductions in overall tobacco use and in the prevalence and intensity of use, with greater impact
Monograph 21: The Economics of Tobacco and Tobacco Control
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on key subpopulations (e.g., young people and people with low incomes). Additionally, studies have
assessed the impact of tax and price on specific outcomes, such as prevalence of tobacco use, smoking
cessation, initiation of smoking by youth, cross-price elasticity, and health outcomes.
Changes in tobacco consumption induced by changes in the excise tax and retail price are reflected in
the price elasticity of demand: the responsiveness of consumption to increased price. Much of the recent
evidence indicates that demand for tobacco products in LMICs is at least as responsive to price as
demand in HICs, and likely more responsive. In HICs, most estimates of elasticities of demand range
from –0.2 to –0.6, clustering around –0.4. In LMICs, elasticity estimates range from –0.2 to –0.8,
clustering around –0.5. Thus, in HICs a 10% increase in the price of cigarettes may be expected to
decrease tobacco consumption by 4%, while in LMICs a 10% increase in price may be expected to
decrease consumption by 5%.
An extensive and increasingly sophisticated body of research clearly demonstrates that higher tobacco
product taxes and prices lead to reductions in tobacco use by motivating current users to quit, preventing
young people from taking up tobacco use, and reducing the frequency and intensity of consumption
among those who continue to use tobacco. In addition, research generally shows that vulnerable
populations, most notably young people and lower income population, are more responsive to tax and
price increases than older people and higher income populations. Finally, a small but growing literature
demonstrates that the reductions in tobacco use that result from higher taxes and prices reduce the
morbidity and mortality caused by tobacco use.
Research Needs
Much is known about the impact of taxes and prices on tobacco use, particularly in HICs, but further
research could be useful. Reliable estimates of overall price elasticities of demand for tobacco products
and estimates of the effects of price on prevalence, initiation, and cessation are not available for many
LMICs. Relatively little is known about how price elasticity changes over time, at different levels of tax
and price, or for larger and smaller price changes. Although cigarettes are the predominant form of
tobacco used around the world, other tobacco products (smokeless tobacco, waterpipe tobacco, bidis,
and others) are commonly used in some countries. However, few studies have assessed the price
elasticity of demand for tobacco products other than cigarettes, and even fewer have estimated cross-
price elasticities; where applicable, these studies will be very useful. Although a small but increasing
number of studies have emphasized the importance of affordability of tobacco products, more research
is needed to understand how changes in affordability affect tobacco use.
Chapter Conclusions
1. A substantial body of research, which has accumulated over many decades and from many
countries, shows that significantly increasing the excise tax and price of tobacco products is the
single most consistently effective tool for reducing tobacco use.
2. Significant increases in tobacco taxes and prices reduce tobacco use by leading some current
users to quit, preventing potential users from initiating use, and reducing consumption among
current users.
3. Tobacco use by young people is generally more responsive to changes in taxes and prices of
tobacco products than tobacco use by older people.
Executive Summary
22
4. Demand for tobacco products is at least as responsive and often more responsive to price in
low- and middle-income countries as it is in high-income countries.
Chapter 5. Design and Administration of Taxes on Tobacco Products
Overview
Tobacco taxation has become a critical component of tobacco control policy as well as an effective tool
for raising government revenue. This chapter examines the impact of the design and administration of
tobacco tax policies on both public health and revenue outcomes. The following topics are considered:
Tobacco taxation approaches, with examples of the way tobacco excise taxes are implemented
around the world
The effects of types of excise taxes on factors such as pricing, product substitution, product
differentiation, and tax avoidance
The challenges of tobacco tax administration, particularly for low- and middle-income countries
with limited resources
Political considerations in formulating tobacco tax policy.
At present, tobacco taxes and tax policies vary widely across different countries. Further increases in
tobacco taxes remain a promising avenue in the global effort to reduce tobacco use.
Chapter Summary
Tobacco products, particularly cigarettes, are subject to a number of taxes, including excise taxes, value-
added taxes (VAT) or sales taxes, and import duties, with excise taxes accounting for the largest share of
retail prices in most countries. Since excise taxes increase the prices of tobacco products relative to other
goods and services, they are considered an important tobacco control tool. A majority of countries tax
cigarettes, but the structure of excise taxes varies greatly across countries.
Higher taxes on tobacco products increase tax revenues and improve public health, but they are an
underused intervention. Governments can promote public health and collect higher revenues in an
efficient and effective way by selecting and imposing the appropriate types and rates of tobacco excise
taxes. Compared to ad valorem taxation, specific taxation better achieves public health objectives
because it increases retail prices and narrows price gaps, thus reducing consumers’ incentives to change
from higher priced to lower priced brands or to other (non-cigarette) tobacco products.
Tobacco products are often subject to differential tax treatment. Typically, higher taxes are levied on
cigarettes and lower taxes are levied on other tobacco products. Increasing excise taxes on cigarettes but
not on other tobacco products (or increasing excises on other tobacco products at a lower rate) will result
in lower prices for those tobacco products relative to the price for cigarettes. Consequently, the overall
reduction in tobacco use will be smaller than if taxes on cigarettes and other tobacco products are
increased by comparable amounts. To reduce the already existing price gap, lessen the likelihood that
consumers will switch to less expensive tobacco products, and maximize the public health impact, tax
increases may need to be greater for other tobacco products than for cigarettes.
The various types of excise taxes each have their relative advantages and disadvantages. Although
specific excise taxation improves public health and tax administration more than ad valorem excises,
Monograph 21: The Economics of Tobacco and Tobacco Control
23
which type of tax should be relied on is less clear when revenue is the primary objective. Specific
excises are better for predicting both the level and stability of revenues, especially when adjusted
regularly to keep pace with inflation. Governments may prefer one type of tax over the other, or prefer a
combination of both, depending on tobacco industry characteristics and political considerations.
A well-designed tax system is one that is simple and easy to administer in order to minimize tax
avoidance and evasion, generate expected revenues, and result in tax increases being passed on to
consumers as price increases. Simplicity in tax systems improves transparency and limits opportunities
for tax avoidance and tax evasion. However, being well-designed is not enough to ensure that a tax
system will have a positive impact on public health and revenues. To ensure high compliance levels,
strong tax administration is needed to implement and administer tax policies efficiently. Compliance can
be strengthened by adopting state-of-the-art monitoring and tracking and tracing systems combined with
strong enforcement.
Research Needs
Much is known about the advantages and disadvantages of specific and ad valorem taxes with respect to
their impact on consumption, prices, and government revenues. However, additional research on how
the tobacco industry’s pricing strategies are influenced by tax structure, tax increases, and market
structure would be informative. Guidance for tax authorities on best practices in tax administration
would also benefit from further research. As more new products, such as ENDS, emerge, research will
be needed to inform the optimal strategies for taxing these products.
Chapter Conclusions
1. Governments have a variety of reasons for taxing tobacco products, including generating revenue
and improving public health by reducing tobacco use. Although price and tax measures are
among the core demand reduction measures of the WHO FCTC, they are among the least
implemented.
2. Almost all governments tax tobacco products, applying a variety of different taxes and using
different tax structures. The different taxes and tax structures vary in their impact on public
health. Relying on import duties to generate revenue is not an effective tax policy and does not
substantially affect public health. More reliance on high, uniform, and specific excise taxes on
tobacco products will have the greatest public health impact.
3. Because of the low share of tax in the retail prices of cigarettes and the relative inelasticity of
demand for tobacco products, increases in tobacco taxes will ensure higher revenues.
4. A number of countries dedicate part of their tobacco tax revenues for health promotion and/or
tobacco control. Dedicating part of tobacco tax revenues for comprehensive tobacco control or
health promotion programs (i.e., earmarking) increases the public health impact of higher
tobacco taxes.
5. An effective tax system is one that is well-designed and -administered. A well-designed system
sets appropriate tax rates to achieve public health and revenue objectives; a well-administered
system ensures high tax compliance and minimizes tax avoidance and evasion.
Executive Summary
24
Chapter 6. The Impact of Smoke-Free Policies
Overview
Secondhand smoke exposure causes numerous serious adverse health effects in adults and children.
Movement toward comprehensive smoke-free policies—those that, by law, completely prohibit smoking
in all indoor workplaces, indoor public places, and forms of transportation—has intensified on an
international scale in response to growing awareness of the negative economic and health consequences
of SHS exposure. This chapter examines:
The economic rationale for comprehensive smoke-free policies
The effect of comprehensive smoke-free policies on SHS exposure, demand for tobacco, and
health outcomes
The economic implications of comprehensive smoke-free policies for various stakeholders
The cost-effectiveness of comprehensive smoke-free policies
The implications of the current literature for low- and middle-income countries.
The evidence clearly demonstrates that comprehensive smoke-free policies reduce exposure to SHS,
have high public support and compliance levels, and do not have negative economic effects on
businesses. These policies also generate reductions in smoking, improve health outcomes, increase
productivity, and reduce health care costs. The tobacco industry has long recognized the potential for
comprehensive smoke-free policies to reduce tobacco use and has sought to weaken or delay
implementation of these policies around the world. Today, however, comprehensive smoke-free policies
are increasingly the norm.
Chapter Summary
SHS exposure is an important cause of disease and death among both children and adults, and imposes
substantial external costs on individuals, governments, and societies. Key information failures, including
inadequate public knowledge of the health hazards of SHS exposure and inefficiencies in the tobacco
market, provide an economic rationale for governments to intervene to reduce the harms caused by
SHS exposure.
Increasingly, national and subnational jurisdictions are adopting comprehensive smoke-free laws in
order to eliminate the negative health effects of SHS exposure on the population. Article 8 of the WHO
FCTC requires Parties to the treaty to adopt and implement effective measures to protect people from
exposure to tobacco smoke in indoor workplaces, indoor public places, public transportation, and, as
appropriate, other public places. The guidelines for Article 8 provide practical guidance for countries to
enact and implement smoke-free policies, and stress that smoke-free legislation should be simple, clear,
and enforceable and should involve civil society as an active partner. Despite recent progress, much of
the world’s population continues to be exposed to SHS in the workplace, in public places, or in the
home. Additionally, in many countries smoking is still permitted in hospitals and other health care
settings, a situation that is particularly important to address because health care professionals and health
care workplaces often serve as examples for other professions and settings. Around the world, the
tobacco industry has been a key factor impeding the enactment of comprehensive smoke-free laws,
because these laws work to reduce tobacco use prevalence and consumption and decrease its social
acceptability, and thus pose a serious threat to the tobacco industry.
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Abundant evidence conclusively demonstrates that the implementation of comprehensive smoke-free
policies improves the public’s health. Hospitality industry workers, because of the intensity and duration
of their exposure, often experience the most immediate benefits of smoking restrictions, including
rapidly improved respiratory and cardiac health. Positive health outcomes associated with smoke-free
policies are observable immediately and are sustained over time. Research also shows that smoke-free
homes yield a double dividend: they reduce exposure to SHS for nonsmoking family members, and they
lead to increased cessation rates among smokers.
Partial restrictions on smoking may reduce SHS exposure but are insufficient to fully protect the health
of exposed individuals. In contrast, comprehensive smoke-free policies are far more effective in
reducing exposure to SHS and improving health outcomes, and are also easier to implement and enforce.
A consensus across much of the literature, particularly among those studies that adhere to rigorous
methodological criteria, is that implementation of smoke-free policies does not cause negative economic
effects for businesses, including hospitality venues such as bars and restaurants. Rather, benefits may
accrue to businesses, including improved productivity, reduced absenteeism, and lower employee health
care costs.
The current research literature is largely focused on the experience of implementing smoke-free laws in
HICs. Fewer studies have been conducted in LMICs, where smoke-free laws have generally been
enacted more recently. With the recent proliferation of smoke-free policies throughout the world, it is
expected that more studies will be conducted in LMICs, which will increase our understanding of how
best to implement laws in these countries and document their health and economic impact.
Research Needs
The WHO FCTC requires Parties to the treaty to implement comprehensive smoke-free policies; the
experience of HICs in implementing these laws has been extensively studied. As these policies become
more common in LMICs, additional research could help determine how best to maximize the ability of
these laws to reduce exposure to SHS, improve health outcomes among nonsmokers, and reduce
smoking. Studies should also assess the economic impact of these laws, both on health care costs and
business revenues, particularly for hospitality sector businesses. Exposure to SHS is not limited to
workplaces and public places; significant exposure—especially of infants and young children—also
occurs in the home, including multiunit housing settings, in HICs and LMICs. Research is needed to
enhance understanding of how best to encourage individuals, landlords, and governments to ban
smoking in these private indoor settings, and to assess the health and economic consequences of these
bans. The question of how comprehensive smoke-free policies affect overall government revenues
remains an area for further study. Finally, as smoking bans in outdoor locations such as beaches, parks,
and other settings become more common, it will be important to understand the health and economic
implications of these measures.
Chapter Conclusions
1. Comprehensive smoke-free policies reduce exposure to secondhand smoke; compliance with
these policies is generally high, and public support for them is strong.
2. Comprehensive smoke-free policies in workplaces reduce active smoking behaviors including
cigarette consumption and smoking prevalence.
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26
3. Overall, rigorous empirical studies (largely from high-income countries) using objective
economic indicators find that smoke-free policies do not have negative economic consequences
for businesses, including restaurants and bars, with a small positive effect being observed in
some cases. Findings from the limited existing research conducted in low- and middle-income
countries are generally consistent with those from high-income countries.
4. Around the world, the tobacco industry is the greatest obstacle to enacting comprehensive
smoke-free policies, often by arguing, despite strong evidence to the contrary, that smoke-free
policies harm businesses.
5. Other economic benefits of smoke-free policies for businesses include increased worker
productivity, health care savings, reduced cleaning and maintenance costs, and reduced insurance
costs.
Chapter 7. The Impact of Tobacco Industry Marketing Communications on Tobacco Use
Overview
The tobacco industry employs a wide array of communications tools to market its products to the public,
from mass media advertising, sponsorship, sales promotions, and packaging, to Internet and new media
strategies. Researchers have examined the influence of industry communications strategies on tobacco
use, particularly among young people, as well as policy interventions to restrict tobacco industry
marketing. Topics covered in this chapter include:
Econometric studies of the impact of tobacco marketing on tobacco use
Econometric studies of tobacco marketing bans and related policies
Population-level cross-sectional and longitudinal studies on consumer response to tobacco
marketing, particularly among young potential smokers and current smokers
The impact of other tobacco marketing efforts such as sponsorship, loyalty incentives, and
tobacco advertising and placement in entertainment media.
An extensive body of research shows that tobacco marketing and tobacco use are causally linked, and
that comprehensive marketing bans are effective in reducing tobacco use. Findings from this research
support the implementation of the World Health Organization Framework Convention on Tobacco
Control, which, under Article 13, legally binds Parties to the treaty to implement a comprehensive ban
on tobacco advertising, promotion, and sponsorship, or restrictions for Parties that are not in a position
to implement a comprehensive ban due to their constitution or constitutional principles.
Chapter Summary
Scholars in many countries and from many disciplines have investigated the relationship between
tobacco marketing and tobacco use, particularly youth use of tobacco products. The extensive body of
evidence on this topic includes econometric studies, population-level cross-sectional and longitudinal
analyses, and others. Several authoritative reviews, including those conducted by NCI, the U.S. Surgeon
General, and the Cochrane Collaboration, have concluded that advertising and promotion are causally
linked to youth smoking initiation. Studies conducted since these reviews confirm and extend
these findings.
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Research has also demonstrated the effectiveness of tobacco product marketing bans, and WHO has
concluded that comprehensive bans on tobacco advertising, promotions, and sponsorship (TAPS) are a
“best-buy” measure to reduce tobacco use. A new analysis conducted for this chapter also confirms that
comprehensive bans on tobacco advertising have a significant negative effect on consumption, reducing
tobacco consumption by 28.3% in LMICs and by 11.7% in the full sample of 66 countries (HICs and
LMICs) analyzed.
The WHO FCTC obligates its Parties to implement and enforce a comprehensive TAPS ban, or for those
Parties that are not in a position to undertake a comprehensive ban owing to their constitutions or
constitutional principles, to apply restrictions on tobacco advertising, promotion, and sponsorship that
are as comprehensive as possible. As of 2014, a majority of countries, including HICs and LMICs, now
ban at least some forms of tobacco marketing; bans on television and radio advertising are most
common. More comprehensive bans benefit the public’s health by limiting industry’s demonstrated
ability to adapt to and circumvent regulatory strategies and various types of marketing bans.
Recent studies have also looked at the impact of indirect tobacco marketing, which includes
sponsorship, product sampling, promotional items and brand sharing, tobacco packaging, retail point-of-
sale displays, and entertainment media and product placement. These forms of marketing also promote
tobacco use, as recognized by the WHO FCTC, which defines tobacco advertising and promotion as
“any form of commercial communication, recommendation or action with the aim, effect or likely effect
of promoting a tobacco product or tobacco use either directly or indirectly.”1,p.4 Research conducted in
many countries has shown that the portrayal of tobacco use, including particular tobacco brands, in
movies and other entertainment media normalizes tobacco use among youth. WHO has issued guidance
to assist countries in countering this industry tactic.
The Internet is now a global venue for marketing and sale of tobacco products, accessible to more
potential consumers every day. The Web’s transition from a static forum to one that is interactive,
participatory, and often consumer driven has dramatically changed the nature of Internet marketing.
Researchers have documented that tobacco products are marketed on the Internet in ways that may
attract youth; given the rapidity of change and the scope for reaching young people, this is an important
area for future research.
Lastly, it is now recognized that the many forms of direct and indirect marketing communications do not
operate in isolation; rather, it is the combination of marketing communications that influences the
consumer. In short, as regards marketing communications, the whole is much greater than the sum of
its parts.
Research Needs
A large evidence base documents the causal association between tobacco industry advertising and
smoking among young people. However, there are areas that warrant further research. Documentation
and assessment of the impact of financial or “in-kind” contributions from the industry in exchange for
sponsorship of events, media, and product placement have been limited compared to other areas of
tobacco marketing, with the exception of sports sponsorship and product placement in movies. As
certain segments of entertainment media become more popular and technologically advanced, such as
video/virtual reality gaming, more extensive and creative documentation and study of the effects of
sponsorship or product placement in these media are needed. Similarly, as new media technology
Executive Summary
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emerges and gives rise to different marketing and advertising strategies, such as through the Internet and
social media, research is needed to study the impact of these new types of marketing tools on tobacco
use. These media tools have been heavily used for marketing products, such as ENDS, which are
available to youth in many countries. Novel digital marketing and conventional marketing strategies
may have synergistic effects on tobacco product consumption, particularly by youth—a subject about
which further investigation is needed.
Chapter Conclusions
1. Tobacco companies engage in a wide variety of marketing activities, ranging from traditional
advertising, promotion, and sponsorship to emerging marketing techniques in the digital arena.
These marketing activities have the potential to affect key populations, such as young people and
women, particularly in low- and middle-income countries, who may be particularly susceptible
to these efforts.
2. The weight of the evidence from multiple types of studies done by researchers from a variety of
disciplines and using data from many countries indicates that a causal relationship exists between
tobacco company marketing activities and tobacco use, including the uptake and continuation of
tobacco use among young people.
3. In high-income countries, comprehensive policies to ban the marketing activities of tobacco
companies are effective in reducing tobacco use, but partial marketing bans have little or no
effect.
4. Comprehensive policies to ban the marketing activities of tobacco companies leads to larger
reductions in tobacco use in low- and middle-income countries than in high-income countries.
Chapter 8. The Impact of Information on the Demand for Tobacco Products
Overview
Information failures in the tobacco marketplace provide an economic rationale for governments to
intervene in the tobacco market using a variety of measures. This chapter explores the impact of
information on the demand for tobacco products, including:
Consumers’ limited awareness of the risks of tobacco use, and differences in awareness by
country income group
The role of tobacco industry disinformation practices in consumers’ uptake and continued use of
tobacco
Information interventions—including anti-tobacco mass media campaigns, school-based tobacco
education programs, health warning labels, and interventions focused on tobacco product
packaging—and their impact on the demand for tobacco products.
Research shows that consumers, especially youth, do not appreciate the magnitude of the risks of
tobacco use and tend not to personalize these risks, and that these information failures are generally
greater in low- and middle-income countries than in high-income countries. For this reason,
programmatic interventions and policies to raise awareness of the harms of tobacco use and the
addictive properties of nicotine, and to counter tobacco industry marketing and disinformation efforts
are necessary to help reduce tobacco use.
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Chapter Summary
Information failures provide an economic rationale for governments to intervene to increase public
knowledge about the health harms of tobacco products. Studies conducted in HICs find that although
most smokers demonstrate awareness of the major health consequences of cigarette smoking, significant
knowledge gaps remain, and smokers tend to underestimate the magnitude of the risks of smoking and
tend not to personalize these risks. Adolescent smokers are especially likely to underestimate or discount
the health risks. In general, knowledge of the health risks of tobacco products is thought to be less
widespread in LMICs, where limited government resources and often weak tobacco control
environments make informing the public a greater challenge than in HICs. The tobacco industry’s
decades-long global effort to deny and distort the scientific evidence on smoking and health has
contributed to the public’s limited and inadequate understanding and awareness of the health
consequences of tobacco use and SHS exposure.
Measures that increase public awareness of the risks of tobacco use are important tobacco control
strategies. Indeed, studies conducted in both HICs and LMICs show that various types of interventions
aimed at increasing public knowledge help reduce tobacco consumption. The WHO FCTC requires
Parties to the treaty to adopt a variety of evidence-based measures, including warning labels on tobacco
packages, and to prohibit misleading industry practices, such as the use of “light” and “low-tar”
descriptors on packages. Many countries have implemented anti-tobacco mass media campaigns,
and numerous scientific studies document that these campaigns can reduce smoking prevalence among
both youth and adults. School-based tobacco education campaigns that are implemented as part of
comprehensive tobacco control programs can help reduce tobacco use among youth; these may be
especially useful in countries with low public knowledge about smoking and health. However, youth-
focused campaigns conducted or funded by the tobacco industry have been shown to be ineffective
at reducing youth’s tobacco use or may subvert this goal. Indeed, research has shown that the actual
purpose of these programs is to serve industry’s interests at the cost of the public interest. Large pictorial
health warning messages on tobacco products have now been implemented in many countries around the
world and have been shown to inform smokers and help reduce tobacco use. Among other groups,
pictorial health warnings have the ability to inform both youth and poorly literate adult populations.
Their low cost makes them particularly attractive to governments with limited resources—for example,
LMICs.
In 2012, Australia pioneered the use of plain (standardized) packaging, which requires tobacco products
to be sold in a standardized “drab dark brown” package, with the brand name and any variant name
shown in a (small) standard font, style, and size. This requirement limits the value of the tobacco
package as a marketing vehicle and increases the prominence of the health warning message carried on
the package. Early studies of Australia’s experience already show that the measure is contributing to a
decline in tobacco use by reducing the appeal of tobacco products, reducing the potential for tobacco
packaging to mislead consumers, and enhancing the effectiveness of pictorial health warnings. These
effects are expected to become stronger over time. Despite concerted tobacco industry opposition, a few
countries have passed laws to implement plain packaging, and several other countries have announced
their intention to implement or are considering doing so.
Executive Summary
30
Research Needs
Research is needed to better understand public knowledge of the health hazards of tobacco use and SHS
exposure, including knowledge of vulnerable subpopulations such as youth, the poor, and those with low
or no literacy; these issues are especially important to study in LMICs, where the majority of the world’s
tobacco users now reside. Studies are needed to evaluate the impact of “information shocks” and of
measures to increase public knowledge of the health effects of tobacco use, as these are rolled out in
LMICs. It will also be important to assess the ability of school-based health education efforts in LMICs,
especially when incorporated into broader tobacco control efforts, to both increase knowledge of
tobacco’s hazards and to reduce tobacco use. To date, most studies of the public’s knowledge have
focused on cigarettes; given the diversity of smoked and smokeless products used around the world, and
the entry of products such as ENDS to the market, research should also examine public knowledge of
the health effects of these products.
Research is also needed to assess the impact of policies designed to increase public knowledge,
implemented in response to the WHO FCTC, and to determine what additional policies are needed to
expand and maintain public knowledge. As more countries adopt plain packaging, it will be important to
assess the impact of this measure and how it is influenced by different approaches and implementation
conditions. Finally, continued study of tobacco industry strategies to undermine public knowledge is
also needed, especially in LMICs and among vulnerable populations in HICs.
Chapter Conclusions
1. Imperfect understanding of the impact of cigarette smoking and other tobacco use on health,
particularly in low- and middle-income countries, provides an economic rationale for
interventions to disseminate information about the addictive and harmful nature of tobacco
products.
2. Tobacco industry disinformation practices have directly contributed to the information failures
associated with consumers’ imperfect knowledge of the risks of disease and addiction.
3. Well-designed and -implemented anti-tobacco mass media campaigns are effective in improving
understanding about the health consequences of tobacco use, building support for tobacco
control policies, strengthening social norms against tobacco use, and reducing tobacco
consumption among youth and adults.
4. School-based tobacco education programs, when implemented as part of comprehensive tobacco
control programs, can improve knowledge, contribute to denormalizing tobacco use, and help
prevent tobacco use. Emerging evidence suggests that school-based programs can be as or more
effective in reducing tobacco use among young people in low- and middle-income countries,
where knowledge of the hazards of tobacco use is lower compared with high-income countries.
5. Large pictorial health warning labels on tobacco packages are effective in increasing smokers’
knowledge, stimulating their interest in quitting, and reducing smoking prevalence. These
warnings may be an especially effective tool to inform children and youth and low literacy
populations about the health consequences of smoking.
6. Plain (standardized) packaging (i.e., devoid of logos, stylized fonts, colors, designs or images, or
any additional descriptive language) reduces the appeal of tobacco products, enhances the
salience of health warnings, minimizes consumers’ misunderstanding of the harms of tobacco,
and has contributed to a decline in tobacco use in Australia, the first country to implement plain
packaging.
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7. The stock of information about the harms of tobacco use is subject to potential erosion over time
(wear-out) and needs to be replenished and maintained.
Chapter 9. Smoking Cessation
Overview
Smoking cessation can have an immediate impact on the economic and public health consequences of
tobacco use. This chapter examines current evidence for cessation support and best practices and their
implementation in countries around the world. Specifically, the chapter discusses the following topics:
Health and economic benefits of cessation
Current interventions for smoking cessation, including pharmacological and behavioral
interventions, tobacco quitlines, Web- and mobile-based cessation services, and the integration
of cessation treatments into health care systems
Factors that affect demand for cessation support, including cost and accessibility of cessation
support services and products, the price of tobacco products, and consumer awareness
Effects of tobacco control measures, such as taxation, smoke-free policies, and information and
mass media interventions, on cessation.
Evidence from high-income countries clearly demonstrates the effectiveness and cost-effectiveness of
interventions to promote and support cessation. Less evidence is available on the effectiveness and cost-
effectiveness of cessation interventions in low- and middle-income countries. Demand for cessation
services in low- and middle-income countries exists, but in many of these countries cessation services
are of limited availability or accessibility, or are unaffordable for most of the population.
Chapter Summary
Tobacco dependence is a chronic, relapsing disorder that often requires repeated interventions and
multiple attempts to quit. Most smokers will make many attempts to quit over a lifetime, and
governments can support these efforts by making cessation resources readily available to all smokers
who need them.
Research from HICs clearly demonstrates the effectiveness and cost-effectiveness of interventions to
promote and support cessation, including the use of pharmacological and behavioral treatments,
promotion of cessation by health care professionals, and integration of cessation treatments into health
care systems. Less evidence exists surrounding the adoption and implementation of cessation
interventions in lower income countries. Policy interventions, such as tax increases, health warning
labels, and smoke-free laws, can also stimulate interest in quitting and demand for treatment.
Coordinating promotion of cessation programs and services with implementation of population-level
policy interventions can increase the penetration and impact of such programs and services. Emerging
low-cost technologies (i.e., mobile phones) and systems-level interventions (e.g., using electronic health
record technology to aid in the identification of tobacco users, prompt clinicians to intervene, and guide
intervention via evidence-based treatment algorithms) can facilitate successful implementation of
cessation treatment worldwide.
Executive Summary
32
Article 14 of the WHO FCTC obliges Parties to promote the cessation of tobacco use and adequate
treatment for tobacco dependence. The implementation rate of Article 14 is strongly associated with
country income status. Low-income countries have the lowest rates of service provision, but
implementation of cessation services is often incomplete even in high-income countries.71
Cost is a
substantial barrier to the use of pharmacological therapies and other cessation services, particularly in
LMICs, but also in HICs. Overall, the demand for smoking cessation treatment services is likely to be
lower in LMICs than in HICs because of a lower awareness of the health consequences of smoking in
LMICs, as well as fewer former smokers as role models, fewer limits on and weaker social norms
against smoking, and the higher price of cessation treatment relative to tobacco products.
Research Needs
Most research on the efficacy and cost-effectiveness of cessation interventions has been conducted in
high-income countries and has focused on cigarettes—by far the most common tobacco product used in
these countries. This discussion of research needs generally focuses on cigarettes, although other
tobacco products (e.g., bidis, smokeless tobacco, waterpipe tobacco) account for a significant proportion
of tobacco consumption in certain regions of the world, and deserve attention in their own right.
Research is needed to evaluate adoption and implementation of interventions to reduce tobacco
consumption and promote cessation in LMICs, where uptake of cessation interventions is lower.
Economic analyses are needed to help LMICs determine the cost and effectiveness of offering various
forms of cessation treatment and prioritize more cost-effective options. Implementation research is
needed to determine how LMICs might use existing infrastructure to achieve the best possible reach as
quickly as possible, at the lowest cost possible. Studies are needed, for example, on strategies for
providing low-cost pharmacological therapies for smoking cessation in LMICs, perhaps through bulk
purchases at the country or regional level or by making pharmacological therapies freely available. In
addition, research is needed to help LMICs develop cessation strategies and treatment guidelines that are
culturally sensitive and to increase demand for treatment among smokers. Research initiatives, such as
the NIH’s International Tobacco and Health Research and Capacity Building Program, can help build
research capacity by supporting international research collaborations between investigators in the
United States and scientists/institutions that are pursuing research on tobacco control and prevention
in LMICs.13
Chapter Conclusions
1. Rates of tobacco cessation among current tobacco users will need to increase in order to
significantly reduce the health consequences of tobacco use worldwide, in both the short and mid
term.
2. Tobacco control policies, such as increased taxation, anti-smoking media campaigns, and
comprehensive smoke-free policies, increase the demand for tobacco dependence treatment and
the rates of subsequent cessation.
3. Research from high-income countries demonstrates that a number of effective and cost-effective
tobacco dependence treatments can increase the likelihood of successful cessation. Relatively
little evidence is available on the effectiveness and cost-effectiveness of tobacco dependence
treatments in low- and middle-income countries and on the transferability of effective
interventions from high-income countries to low- and middle-income countries.
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4. Demand for cessation support exists in low- and middle-income countries, but in most of these
countries, cessation services and products are often of limited availability or accessibility, or are
unaffordable for most of the population.
Chapter 10. Tobacco Growing and Tobacco Product Manufacturing
Overview
Tobacco-growing practices and policies influence the supply of tobacco and can have important
implications for tobacco use and tobacco control. In many countries, tobacco is a part of the farm and/or
manufacturing sector. This chapter examines current issues related to tobacco growing and
manufacturing, including the following topics:
Economic and policy aspects of tobacco growing
Crop substitution and diversification programs, particularly in low- and middle-income countries
Tobacco product manufacturing
The potential for tobacco product regulation to reduce tobacco use.
Policies encouraging crop diversification or substitution may be useful as part of a comprehensive
strategy to reduce tobacco use. Research has demonstrated that alternative crops can be at least as
profitable as tobacco, but many of these alternatives require investments in infrastructure, and tend to be
highly specific to a country or region. The design and manufacturing of tobacco products have changed
substantially over time, both as a result of efforts to allay consumers’ concerns about health harms, and
to reduce costs to manufacturers. However, these changes generally occurred in the absence of
regulation and were sometimes harmful to public health. An important goal of tobacco product
regulation is to ensure that future changes to tobacco products benefit public health. The evidence base
for regulating tobacco products in the context of a rapidly evolving marketplace continues to grow, and
tobacco product regulation is now recognized as an important component of a comprehensive approach
to tobacco control.
Chapter Summary
Tobacco is grown in 124 countries, but by far the largest proportion of tobacco (92% in 2013) is grown
in LMICs; more than 40% of the world’s tobacco is produced in the People’s Republic of China alone.
Tobacco farming accounts for only a small share (<3%) of the global tobacco market. Tobacco growing,
a very labor-intensive process, is believed to provide income to millions of families in the major
tobacco-producing countries, although reliable estimates of the number of people involved are difficult
to obtain.
Tobacco growing and manufacturing are increasingly concentrated in LMICs, but the higher value
phases of the tobacco value chain increasingly take place in a small number of highly profitable
multinational tobacco companies (MTCs), largely based in HICs. Additionally, the global tobacco leaf
market is dominated by large multinational tobacco product manufacturers and leaf traders. Recent
trends in the organization of the tobacco leaf production and marketing chain, including use of
integrated production systems, has expanded these multinational corporations’ control over price and
other factors while making farmers increasingly dependent.
Executive Summary
34
The manner and extent of government intervention in tobacco growing vary considerably from country
to country. Historically, in HICs, particularly in the United States and the European Union (EU), efforts
to support tobacco growing mainly relied on tobacco price supports. In LMICs, where tobacco can be an
important source of foreign exchange and tax revenue, support programs are less focused on
guaranteeing minimum prices to tobacco farmers and more concerned with restricting imports and
improving infrastructure facilities that support expansion of tobacco-farming activities.
The global trend toward reducing or eliminating tobacco subsidies and price supports in HICs has
significantly affected international production and trade patterns. Specifically, production has dropped in
HICs that have phased out price supports, such as the United States, Canada, and traditional producing
members of the EU like Greece and Italy. At the same time, tobacco production has increased in China,
Brazil, Argentina, and in the three main producing countries of Africa—Malawi, Zimbabwe, and
Zambia. In response to the declining production of good quality leaves in HICs, some of the main
producers in LMICs have improved the quality of leaf they grow and have received increased farm
gate prices.
There is a consensus that helping small farmers switch from tobacco to alternative crops can be a useful
part of sustainable local economic development programs and can help overcome barriers to adopting
and implementing strong tobacco control policies. Implementing successful crop substitution and
diversification programs and supporting farmers’ transition to alternative livelihoods require an
understanding of the characteristics of tobacco-farming systems in producing countries and of the
linkages between growers and tobacco companies. Tobacco is an expensive crop to grow, but so too are
most high-value alternative crops. Research has shown that there are viable alternatives to tobacco
farming, but these tend to be specific to individual countries and regions. Building new, and hopefully
better, support systems for other crops is a clear challenge for diversification programs. It will take time
for these systems to emerge, and any successful transition from tobacco will likely be a gradual process.
Tobacco product manufacturing is another key component in the tobacco supply chain and a major
determinant of the impact of tobacco on public health. Since the mid-19th century, cigarettes have
undergone significant changes in design. Modern cigarettes have been extensively engineered to include
the use of additives and design features to deliver nicotine as efficiently as possible. These product
changes have contributed to increased tobacco use and have created market power for the innovating
firms. Some product design changes have been made in response to the public’s increasing awareness of
the health consequences of tobacco use, while others have been made to appeal to more consumers or to
reduce manufacturers’ costs. Product innovations likely contributed to attracting new users and may also
have led some smokers, who would otherwise have quit, to continue to smoke. During the first decade of
the 2000s, new products have emerged in the United States and elsewhere, including ENDS.
In the past, the evolution of cigarettes and other tobacco products in the United States and elsewhere has
occurred in the absence of regulatory authority; as a result, these changes have sometimes harmed public
health. A key goal of tobacco product regulation is to ensure that future changes in tobacco products
benefit public health. Effective interventions for tobacco product regulation face many challenges, given
the variety of tobacco products, the diversity of the tobacco industry, and the difficulties in assessing the
health impact of the constituents and emissions of tobacco products. These challenges are likely to be
greater in LMICs, where technical capacity is more limited and resources scarce. Given these
challenges, the sharing of research and other information across countries, as well as the scientific
and technical cooperation called for in Articles 21 (Reporting and exchange of information) and
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22 (Cooperation in the scientific, technical, and legal fields and provision of related expertise) of the
WHO FCTC will be particularly important in advancing tobacco product regulation. The optimal policy
response in a rapidly evolving market of tobacco products remains an area for further study.
Despite these challenges, it is clear from past experience with changes in tobacco product design that
tobacco product regulation is a necessary component of a comprehensive tobacco control strategy. To
date, however, few countries have adopted wide-ranging product regulations, although many have
adopted policies that narrowly regulate some aspects of tobacco product design or availability. Product
regulation can be expected to advance in the coming years as Parties to the WHO FCTC further develop
and implement guidelines on Articles 9 (Regulation of the contents of tobacco products), 10 (Regulation
of tobacco product disclosures), and further implement Article 11 (Packaging and labelling of tobacco
products).
Research Needs
Tobacco growing, product manufacturing, and tobacco product regulation are the focus of a number of
ongoing research needs. These three subjects have received limited research to date compared with other
aspects of tobacco control, and increased research attention to these areas is important, especially in
LMICs. Research on the economics of tobacco growing, including issues such as the profitability of
tobacco farming and the structure of the leaf-buying industry and value chains, is needed in order to
understand the impact of tobacco production on countries. Research is also needed on the potential
adverse effects of tobacco growing on the health of farmworkers, the environment, and farmers’
livelihoods, and on potential alternatives to tobacco growing in various contexts. The development of a
general analytic framework aimed at providing guidelines for implementing crop diversification and
substitution programs in LMICs is an important research priority.
The diversity of tobacco products in use around the world, as well as the introduction of new products
such as ENDS, poses challenges for product regulation. A greater understanding of the characteristics of
new and emerging products, including their addictive potential and their harmful constituents, would
inform regulatory efforts. It is essential to document and learn from the experience of countries such as
Brazil, Canada, the United States, the United Kingdom of Great Britain and Northern Ireland, and others
as they put in place new regulations for tobacco products. Research evaluating comprehensive product
regulation strategies, including their impact on patterns of tobacco use and health outcomes, would
inform the evolution, adoption, and implementation of future regulatory actions.
Chapter Conclusions
1. In 2013, ten countries accounted for most of the world’s tobacco leaf production (80%); China
alone produced more than 40% of the world’s tobacco leaf. Tobacco is increasingly grown in
low- and middle-income countries, and many of these countries export a large proportion of the
world’s tobacco leaf.
2. In the past, governments have sought to control price and quantity in the tobacco leaf market
through quotas and pricing restrictions and to provide technical assistance to tobacco growers,
along with other agricultural producers. Although most high-income countries have reduced or
eliminated subsidies for tobacco growing, many low- and middle-income countries still provide
support for the tobacco-growing sector.
Executive Summary
36
3. The vast majority of workers in the tobacco production chain are tobacco farmers doing highly
labor-intensive work on small family farms, which are increasingly located in low- and middle-
income countries. In contrast, cigarette manufacturing—the higher value phase of the chain—is
highly mechanized and dominated by a few large multinational corporations largely based in
high-income countries.
4. Tobacco growing is relatively profitable, but farming of other crops has the potential to be as or
more profitable than tobacco growing. Alternatives to tobacco growing tend to be highly specific
to a country or region. Policies that encourage crop diversification or substitution are useful as
part of a comprehensive tobacco control strategy, but alone they will have little impact on
tobacco use.
5. Changes in product design—often made in response to consumer concerns about the adverse
health consequences of tobacco as well as to reduce costs to the manufacturer—have likely
contributed to increased tobacco use.
6. Product regulation is a rapidly developing component of a comprehensive tobacco control
strategy. Regulation of tobacco products is a highly technical area, which poses many challenges
for regulators, including challenges relating to the diversity of products, the ability of the tobacco
industry to respond quickly to changing market conditions, and the need for sufficient capacity
for testing and enforcing regulatory measures; addressing these issues is likely to be particularly
challenging for low- and middle-income countries.
Chapter 11. Policies Limiting Youth Access to Tobacco Products
Overview
This chapter examines policy interventions designed to limit youth access to tobacco products and
reviews issues related to the global implementation, enforcement, and impact of these policies. Key
areas of discussion include:
Sources of tobacco products among youth and measures of levels of youth access to tobacco and
their variation by world region and World Bank country income group
Types of youth access policies and their intended impacts
Research on the implementation and enforcement of youth access policies and the impact of
these policies on youth access to tobacco and youth smoking
Limitations of youth access policies—in particular, how the necessary infrastructure and
resources for implementing and enforcing such policies may pose challenges, particularly for
low- and middle-income countries, and how the tobacco industry’s involvement with these
interventions can undermine broader tobacco control efforts.
In high-income countries, youth access policies, when consistently enforced, can reduce commercial
access to tobacco products among youth. Evidence from high-income countries suggests that strongly
enforced youth access policies that successfully disrupt the commercial supply of tobacco products to
minors can reduce youth tobacco use, although the magnitude of this effect is relatively small. The
limited evidence on the impact of youth access policies implemented in low- and middle-income
countries suggests that they can be effective in reducing youth tobacco use in these settings, although the
amount of reduction is unclear.
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Chapter Summary
Youth access policies are intended to limit the commercial supply of tobacco products to youth, with the
goals of preventing or delaying initiation of tobacco use by youth and reducing underage consumption,
changing social norms about smoking, and decreasing overall smoking prevalence. A variety of policy
measures are available to regulate the sale and distribution of tobacco products to youth. These measures
are economically justified on the grounds that failures in the market for tobacco products are particularly
pronounced during the ages at which most tobacco use begins. Youth access policies are most common
in high-income and upper middle-income countries. When consistently enforced, these policies can
effectively reduce commercial access to tobacco products among underage youth. However, sufficient
resources are needed to implement and enforce these policies well enough to effectively limit the
commercial supply of tobacco to youth.
Evidence from HICs about the effectiveness of youth access policies in reducing youth smoking is
mixed. Strongly enforced youth access policies that successfully disrupt the commercial distribution of
tobacco products to underage youth appear to reduce youth tobacco use, although the magnitude of this
effect is relatively small. More research is needed to evaluate the impact of youth access policies in
LMICs; emerging evidence suggests these policies can be effective in reducing youth smoking in
LMICs although the amount of reduction is unclear. The evidence indicates that youth access policies
are likely to have a greater marginal impact in countries with relatively weak overall tobacco control
policies and programs. Moreover, the absence of youth access laws sends mixed messages about the
harm posed by the use of tobacco and the importance of other youth tobacco prevention efforts. Efforts
to limit youth access to tobacco products, although of limited influence as stand-alone measures, are an
important component of a comprehensive strategy to reduce tobacco use.
Research Needs
Most of the evidence on the efficacy and cost-effectiveness of youth access policies reflects the
experiences of HICs. More evidence is needed to evaluate the adoption, implementation, and impact of
various youth access interventions in LMICs. Specific research needs in LMICs include continued
monitoring of tobacco sales to minors and ongoing evaluation of enforcement and compliance measures
in countries with existing youth access policies. In both HICs and LMICs, research could further inform
other policy approaches for limiting youth access to tobacco, including bans on self-service displays,
and regulation of the number, density and location of tobacco retail outlets within communities. As
noted previously, a growing number of U.S. states and localities are raising the minimum age of legal
access to tobacco products to 21 years; research to understand their experiences will help inform the
evidence base for youth access policies going forward in the United States and elsewhere.
Chapter Conclusions
1. Information failures in the market for tobacco products are particularly pronounced during the
ages at which most tobacco use begins, providing an economic rationale for interventions to limit
youth access to tobacco products.
2. Youth access policies, when consistently enforced, can reduce commercial access to tobacco
products among underage youth. Sufficient resources are needed to implement and enforce these
policies well enough to effectively limit youth access to commercial sources of tobacco.
Executive Summary
38
3. Evidence from high-income countries indicates that strongly enforced youth access policies that
successfully disrupt the commercial supply of tobacco products to underage youth can reduce
youth tobacco use, although the magnitude of this effect is relatively small.
4. Emerging research suggests that youth access policies can also be effective in reducing youth
tobacco use in low- and middle-income countries, although the amount of reduction is unclear.
Chapter 12. Tobacco Manufacturing Privatization and Foreign Direct Investment and Their Impact on Public Health
Overview
The inflow of foreign direct investment (FDI) and the privatization of state-owned tobacco enterprises
have increased for two reasons: (1) the rising globalization of industry in general and (2) the trend
toward fewer government-owned business monopolies. This chapter examines the forces that drive FDI
and privatization and their impact on global tobacco control efforts and public health. Specifically, this
chapter discusses:
The broad rationale for foreign stakeholders to invest in the tobacco industry, including
globalization trends, FDI policies, and economic factors—particularly in low- and middle-
income countries, where tobacco may attract the largest amount of such investment
The economic and political issues surrounding the privatization of state-owned cigarette
manufacturing industries
The current global ownership status of tobacco industries, by WHO Region
Public health concerns that arise from FDI and privatization trends, including the multinational
tobacco companies’ motivation to expand markets, the economic and political leverage that
influences tobacco control policies, and the impact of increased production differentiation and
pricing.
Country-specific cigarette consumption trends show that FDI and privatization of tobacco enterprises are
not inherently bad for tobacco control. When the privatization of state-owned cigarette manufacturing
industries occurs transparently and without obligations to manufacturers, privatization removes the
conflicts of interest from governments that own their tobacco industries. Unfortunately, these conditions
have not been the norm.
Countries that implement strong and comprehensive tobacco control policies following privatization
have been effective in reducing tobacco use. In contrast, tobacco use has increased in countries without
these policies. These results, in conjunction with the economic and social trends that surround FDI and
privatization, underscore the importance of both public health policy and appropriate regulatory
frameworks in the ongoing evolution of global ownership and investment trends in the tobacco industry.
Chapter Summary
Globalization is an inexorable trend for industries in general, including tobacco. Two key aspects of
globalization are investment and trade.
The clear trend is toward further concentration of the tobacco industry in the hands of a few large
MTCs. This concentration is driven in part by global initiatives to reduce investment barriers through
bilateral and multilateral trade agreements. These initiatives enable MTCs to seek production
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efficiencies, lower costs, and extend their markets at a time when governments have been increasingly
privatizing to raise capital and reduce debt. Thus, forces for privatization and FDI as well as mergers
and acquisitions affect the process of industry consolidation, a process that is at work in the tobacco
industry as well as in many other industries.
Concentration in the tobacco industry has resulted in substantial consolidation, such that five firms
(four MTCs and one state-run company) controlled 85% of the global tobacco market as of 2014.
These trends have had differing specific results in different countries, though it is clear that privatization
and consolidation in this sector pose major challenges for public health efforts. Going forward, this
environment presents both a major challenge and an opportunity for public health. On the one hand,
many countries have been and are at risk from the marketing of tobacco products, and many
privatization agreements have had a negative impact on tobacco control efforts. On the other hand, with
tobacco manufacturing now in the hands of the private sector in most countries, governments may be
able to move forward with tobacco control and public health efforts without the conflicts of interest
inherent in operating state-owned tobacco enterprises.
Privatization was largely completed by the end of 20th century, when state-owned facilities changed
ownership either fully or partially to MTCs in most countries worldwide, with a few exceptions. China’s
state-owned tobacco company, with over 40% of the world’s cigarette market share distribution, is the
major exception. Many governments had great expectations from these transfers to foreign investors,
including higher export earnings, greater employment opportunities in tobacco production, increased tax
revenues, and a higher standard of living for tobacco farmers due to better yields, quality, and prices for
tobacco production supported by the MTCs. As a result, governments are often reluctant to enact strong
tobacco control policies in hopes that multinational tobacco companies will stay in their countries and
fulfill these expectations. Currently, however, little or no research shows the extent to which MTCs have
met these expectations. At the same time, as part of ongoing consolidation and cost-cutting practices,
MTCs have been closing their production facilities in a number of countries, costing governments
unemployment benefits and loss of tax revenues from income and profit taxes. MTCs may use the threat
of such consolidation to influence decision-makers toward weaker tobacco control policies.
Additionally, following trends in global trade, tobacco companies have sought to use trade agreements
and international investment agreements to challenge tobacco control laws in some countries. This
practice follows the tobacco industry’s history of using litigation as a systematic strategy against tobacco
control policies, at both the local and national levels, in many countries. The advent of trade and
investment treaties has created new opportunities for tobacco product manufacturers and their
representatives to delay or obstruct tobacco control policies around the world. Because of its vast
financial resources, the tobacco industry is a formidable opponent in litigation; the industry’s resources
often dwarf those of countries and subnational jurisdictions that must defend their policies. Sometimes
the mere threat of litigation may be sufficient to intimidate countries into delaying or abandoning
tobacco control measures. Recently, countries negotiating the Trans-Pacific Partnership Agreement have
recognized this problem by adding, for the first time in any trade agreement, a general exception that
allows any party the right to deny the benefits of investor–state dispute settlement with respect to any
claims challenging a tobacco control measure.14
Executive Summary
40
Research Needs
Recent studies have provided crucial evidence of the correlation between privatization, market
liberalization, and investment in the growth and efficiency of the tobacco industry. However, ongoing
research is needed to continue to study the long-term impact of privatization and FDI in different
environments as well as trends in tobacco use in countries that retain government ownership of tobacco
enterprises. This research is essential, and it should be expanded to focus on China’s state monopoly, its
impact on tobacco control, and its relationships with other global tobacco companies. As with other
aspects of tobacco control, ongoing surveillance is needed to monitor the use of international trade and
investment treaties to influence tobacco control policies.
Research is also needed to better understand tobacco industry strategies to both shape and use trade and
investment treaties to promote tobacco use and to interfere with countries’ efforts to implement tobacco
control policies that accord with the WHO FCTC and its guidelines. Research is needed regarding the
tobacco industry’s strategies and tactics to counter tobacco control measures—to block, diminish, or
delay implementation of the most innovative and robust components of tobacco control—as well as the
options available to countries to address these industry actions.
Chapter Conclusions
1. Over the past few decades, the privatization of domestic tobacco companies and direct
investment by multinational tobacco companies, particularly in low- and middle-income
countries, have contributed to the globalization of the tobacco industry.
2. The impact of privatization on public health is varied and is influenced by the strength of
domestic regulation. Some countries have implemented strong tobacco control measures after
privatization, leading to reductions in tobacco use. However, in the majority of countries,
privatization leads to significantly greater efficiency and production, massive marketing
campaigns, and increased cigarette consumption—particularly among women and young people.
3. China’s state tobacco monopoly is a market leader, with over 40% of global cigarette market
share, almost all of which is consumed domestically. The China National Tobacco Corporation
appears poised to expand beyond domestic sales by using foreign direct investments,
partnerships with multinational tobacco companies, development of an international supply chain
to support its premium brands, and by other means.
4. Increasingly, the tobacco industry is using trade and investment treaties to challenge innovative
tobacco control policies. The tobacco industry also uses the threat of litigation, with its attendant
costs, and lobbying campaigns to deter governments from advancing tobacco control policies,
especially in low- and middle-income countries.
Chapter 13. Licit Trade in Tobacco Products
Overview
The liberalization of trade in recent decades has affected the global market for tobacco products and has
been shown to affect cigarette consumption, particularly in low- and middle-income countries. This
chapter examines the current state of licit trade in cigarettes and tobacco leaf and its impact on tobacco
control efforts. Specific topics include:
Import, export, and price trends for both cigarettes and tobacco leaf across different countries
and world regions
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The potential impact of trade liberalization on cigarette consumption, as revealed by a review of
the literature and by economic analyses
Global, regional, and bilateral trade agreements and their impact on tobacco use.
The current trade environment for tobacco leaf and tobacco products underscores the importance of
implementing and enforcing effective tobacco control policies, particularly in ways that do not
discriminate between imported and domestic products. Broad policies, such as tobacco excise tax
increases, bans on smoking in public places and workplaces, packaging and labeling measures, and
comprehensive bans on marketing, are important tools for controlling tobacco use and mitigating the
impact of trends in international trade.
Chapter Summary
Trade in tobacco leaf accounts for a very small proportion (<1%) of global agricultural imports and
exports. A few countries, however, rely heavily on export earnings from tobacco leaf; in 2012, these
included Zimbabwe, Malawi, Macedonia, Bangladesh, Zambia, and Tanzania. A small number of
countries dominate the global export of tobacco leaf—five countries exported more than half of the
world’s tobacco leaf in 2012. The import of tobacco leaf is also dominated by a small number of
countries; five countries together accounted for nearly 40% of global tobacco leaf imports in 2012.
The value and quantity of global tobacco leaf exports and imports have trended upward over the last
30 years. Since the late 1990s, upper middle-income countries have been the largest exporters of tobacco
leaf, with countries in the Americas Region, Brazil in particular, being dominant. HICs, especially those
in the European Region, have been the largest tobacco leaf importers for many decades.
Although many countries participate in either the export or import of manufactured cigarettes, this
product accounts for a very small share of overall global trade. For example, in 2012, trade in cigarettes
(both exports and imports) accounted for only 0.11% of the world’s total trade value in goods and
services. As with tobacco leaf, trade in cigarettes is dominated by a relatively small number of countries.
In 2012, five countries accounted for nearly half of the world’s cigarette exports, primarily HICs, in the
European Region. Similarly, five countries accounted for about one-third of the world’s cigarette
imports, and again, European Region countries accounted for the largest share.
Both the quantity and value of world cigarette exports have increased in the last several decades, with
steep rises seen particularly in the late 1980s and early 1990s. These rises coincided with expansion of
the General Agreement on Tariffs and Trade, an increased number of bilateral and multilateral trade
agreements, and other factors reflecting increased economic globalization.
The price-instability index is considerably lower for tobacco leaf than for other agricultural products;
this relative stability may well be one of the reasons that farmers find the crop attractive to grow. The
export price of cigarettes from HICs has exceeded the price of cigarettes exported from LMICs for many
decades, probably reflecting the higher production costs and higher quality of cigarettes produced in
HICs. With regard to cigarettes, higher quality does not refer to the health impact of the product, rather
it reflects features such as packaging, flavoring, or other product design features which may increase the
appeal to consumers.
Executive Summary
42
The increase in tobacco trade has been facilitated by adoption of a variety of international, regional, and
bilateral trade agreements which have reduced tariff and non-tariff barriers to trade for a variety of
goods and services. Trade in tobacco has also increased as a result of foreign investment, as described in
chapter 12. In addition to the World Trade Organization agreements, the number of regional and
bilateral trade and investment agreements has increased sharply since the early 1990s, providing
opportunities for multinational companies, including tobacco companies, to enter or increase their
presence in new markets.
Trade agreements have implications for the availability and accessibility of tobacco-related goods and
services within and across countries and, as a result, for tobacco consumption. A number of studies have
analyzed the impact of trade liberalization on tobacco consumption, and all have concluded that
expanded trade in tobacco products has led to an increase in consumption. The new estimates presented
in this chapter also show that increased trade openness increases cigarette consumption globally, with a
greater impact on low-income countries, where tobacco control measures are generally weaker than in
middle- and high-income countries.
Further liberalization of trade in tobacco leaf and tobacco products can be expected to increase tobacco
product consumption, particularly in low-income countries. However, governments have many tools
available to avert a rise in consumption, including tobacco excise tax increases, bans on smoking in
public places and workplaces, packaging and labeling measures, and comprehensive bans on marketing.
Such policies may be introduced or strengthened but should be nondiscriminatory and necessary to
protect public health.
Research Needs
In an increasingly globalized world, global, regional, and bilateral trade agreements will continue to
exert an important influence on tobacco use and tobacco control efforts. There is a continued need to
understand how specific trade agreements, and trade liberalization in general, impact trade in tobacco
and tobacco products, tobacco consumption, and tax evasion, and how the entry of products from
multinational tobacco companies can affect the pricing and marketing strategies of local companies.
Research is also needed on how trade agreements influence adoption and implementation of tobacco
control policies. How tobacco companies and their allies may seek to shape the contours of trade
agreements to advance their business models and spur growth (or hamper decline) in tobacco
consumption is also an important focus for further research.
Chapter Conclusions
1. Trade in tobacco leaf accounts for a very small proportion (<1%) of global agricultural imports and exports, and very few countries rely heavily on earnings from trade in tobacco leaf.
2. Although many countries participate in either the export or import of manufactured cigarettes,
these products account for only a very small share of overall global trade in goods and services.
3. International, regional, and bilateral trade agreements have reduced tariff and non-tariff barriers
to trade, increased trade in tobacco leaf and tobacco products, and contributed to the
globalization of the tobacco industry.
4. Increased liberalization of trade has contributed to increased tobacco use in low- and middle-
income countries. During the period when trade in tobacco products was liberalized, most low-
and middle-income countries had weak or no tobacco control measures in place.
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5. Recent World Trade Organization decisions involving challenges to domestic tobacco control
policies suggest that governments can address public health concerns associated with increased
liberalization of trade in tobacco leaf and tobacco products by adopting and implementing
effective tobacco control policies and programs that apply evenly to domestic and foreign
tobacco growers and manufacturers.
Chapter 14. Tobacco Tax Avoidance and Tax Evasion
Overview
Tax avoidance (licit) and tax evasion (illicit) undermine the effectiveness of tobacco control policies,
particularly higher tobacco taxes. These activities range from legal actions such as purchasing tobacco
products in lower tax jurisdictions, to illegal ones such as smuggling, illicit manufacturing, and
counterfeiting. This chapter examines:
Types of tax avoidance and tax evasion
Measurement of tax avoidance and evasion
Determinants of tax avoidance and evasion
Measures to counteract tax evasion, including the WHO FCTC Protocol to Eliminate the Illicit
Trade in Tobacco Products (ITP).
The tobacco industry and others often argue that high tobacco product taxes lead to tax evasion.
However, the evidence shows that non-tax factors including weak governance, high levels of corruption,
poor government commitment to tackling illicit tobacco, ineffective customs and tax administration, and
informal distribution channels for tobacco products are often of equal or greater importance. Addressing
illicit trade requires concerted attention to these root causes.
Chapter Summary
Circumventing taxes on tobacco products through licit means (tax avoidance) and through illicit means
(tax evasion) undermines the ability of tobacco control policies to reduce tobacco use. The most serious
challenge is posed by large-scale smuggling, because it involves large quantities of tobacco products,
has a greater impact on public health and regional economies, and frequently provides revenue for
organized criminal networks and terrorist organizations. Previously internal tobacco industry documents,
investigative reporting, and litigation show that tobacco companies at the global level have promoted
and facilitated cigarette smuggling.
A variety of methods have been used to estimate the extent of tax avoidance and evasion, including
consulting expert opinion, comparing tobacco product exports and imports, comparing tax-paid sales
with consumption, surveying consumers’ purchasing behaviors, comparing taxed sales with estimated
consumption using demand analysis, and observational methods. Estimating the extent of tax avoidance
and tax evasion is difficult, given that those involved may have a stake in keeping their involvement in
these activities secret.
Large tax differences between jurisdictions create incentives for tax avoidance (e.g., cross-border
shopping) and tax evasion (e.g., bootlegging). These incentives diminish as the distance between
jurisdictions increases. In contrast, the evidence linking price to the level of large-scale illicit trade is
mixed, indicating that factors other than price are equally or more important determinants. Large-scale
Executive Summary
44
illicit trade, generally conducted by criminal networks, flourishes in countries and regions with weak
governance, high levels of corruption, and lax law enforcement, and where smuggling of other
commodities is also common. Illicit trade routes are constantly evolving in response to governments’
efforts to curb illicit trade.
Experience from many countries demonstrates that illicit trade can be successfully addressed, even when
tobacco taxes and prices are raised, and curbing illicit trade results in increased tax revenues and
reduced tobacco use rates. Government commitment to combating illicit trade is essential. Successful
strategies include implementing tracking and tracing systems; controlling the supply chain by licensing
all parties involved in tobacco product manufacturing and distribution; implementing appropriate
policies, stronger enforcement, and enhanced penalties; and international cooperation in investigation
and prosecution of participants in illicit trade.
The ITP, the first protocol of the WHO FCTC, was adopted in November 2012. The ITP recognizes that
illicit trade increases the accessibility and affordability of tobacco products, fuels the tobacco epidemic,
undermines tobacco control policies, reduces government revenues, and helps to fund transnational
criminal activities. Once in force, the ITP will oblige Parties to implement a variety of measures, with
special emphasis on those that strengthen control over the supply chain of tobacco products, and to
cooperate in global efforts to eliminate illicit trade in tobacco products.
Research Needs
Research is needed to better understand the extent of tax avoidance and evasion, and the effectiveness of
interventions to curb them. Generating adequate data on the extent of tax avoidance and evasion is
challenging when illicit activities are involved. Developing reliable measures to determine the
magnitude of the problem is essential, particularly in low- and middle-income countries, given that
much of the existing data on tax avoidance and evasion come from North America and Europe. There is
also a need to understand transfer pricing activities of multinational tobacco companies. A better
understanding of the determinants of illicit trade—including the supply of illicit tobacco products—is
needed in order to maximize the effectiveness of interventions to limit illicit trade. Systematic
evaluations that examine the effectiveness of interventions to reduce illicit trade would contribute to the
evidence base. Lastly, while much of the research to date has focused on cigarettes, illicit trade in other
tobacco products is an area that would benefit from further research.
Chapter Conclusions
1. Tax avoidance and tax evasion, especially large-scale smuggling of tobacco products, undermine
the effectiveness of tobacco control policies and reduce the health and economic benefits that
result from these policies.
2. In many countries, factors such as high levels of corruption, lack of commitment to addressing
illicit trade, and ineffective customs and tax administration, have an equal or greater role in
explaining tax evasion than do product tax and price differentials.
3. Illicit trade has sometimes included the involvement of tobacco companies themselves.
4. Experience from many countries demonstrates that illicit trade can be successfully addressed,
even when tobacco taxes and prices are raised, resulting in increased tax revenues and reduced
tobacco use.
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5. Implementing and enforcing strong measures to control illicit tobacco trade would enhance the
effectiveness of significantly increased tobacco taxes and prices and strong tobacco control
policies in reducing tobacco use and its health and economic consequences.
Chapter 15. Employment Impact of Tobacco Control
Overview
Adoption and implementation of effective tobacco control policy interventions are often influenced by
concerns over the potential employment impact of such policies. This chapter examines employment
issues and discusses the following:
An overview of current tobacco-related employment, including employment in tobacco growing,
manufacturing, wholesale and retail sales, and tobacco-expenditure-induced employment
Trends in tobacco-related employment including the shift toward low- and middle-income
countries
Impact of globalization, increased workforce productivity, and new technologies on tobacco-
related employment
Impact of tobacco control policies on overall employment and how this impact varies based on
the type of tobacco economy in specific countries.
Econometric studies show that in most countries tobacco control policies would have an overall neutral
or positive effect on overall employment. In the few countries that depend heavily on tobacco exporting,
global implementation of effective tobacco control policies would produce a gradual decline in
employment. Around the world, employment in tobacco manufacturing has decreased primarily because
of improvements in manufacturing technology, allowing more tobacco products to be manufactured by
fewer workers, and by the shift from state-owned to private ownership, which requires companies to
operate in a more competitive environment.
Chapter Summary
The tobacco industry generates jobs directly and indirectly in many economic sectors. Employment in
tobacco farming is concentrated in the few countries that are major producers of tobacco leaf, and
research has shown that the share of agricultural employment in tobacco farming has declined over the
years. Global employment in tobacco manufacturing, also concentrated in a few countries, has been
relatively stable over time despite a considerable increase in global production. Tobacco
manufacturing’s share of total manufacturing employment tends to be small and is declining in most
countries. Technology has played a major role in increasing productivity in both tobacco growing and
manufacturing, allowing fewer workers to grow more tobacco leaf and produce more manufactured
tobacco products. Privatization, the shift from state to private ownership, has also tended to reduce
employment by requiring companies to operate in a more competitive environment.
Research on the impact of tobacco control policies on employment focuses on the impact on the tobacco
sector (gross employment impact), or considers employment impact in the tobacco sector along with
other economic sectors to which expenditures might be redirected (net employment impact). Studies of
net impact provide a more complete picture of the effect of tobacco control policies on employment. The
effect of tobacco control policies on employment depends in part on the country’s type of tobacco trade
economy, as categorized by its share of imports and exports: net exporters, balanced economies, net
Executive Summary
46
importers, or mixed economies. Employment effects also differ depending on whether the particular
tobacco control policy of interest impacts the domestic or global tobacco market.
For the vast majority of countries, studies have found that tobacco control policies have had no effect or
a small net positive effect on national employment. For the few countries that rely heavily on tobacco
exports, the economy would incur a transition cost as a result of global tobacco control efforts. Tobacco
farmers in particular could be affected negatively because of the labor-intensive nature of tobacco
farming, their investments in equipment for tobacco production, and because of a lack of resources to
help them adapt to the changing environment. However, domestic tobacco control measures in these
countries would have little effect on national employment.
The challenge of transitioning from tobacco-related employment to other viable economic activities
would be moderate in the long term. The addictive aspect of smoking means that reductions in tobacco
consumption would occur gradually. In fact, the transition to a smaller tobacco economy has been
ongoing in HICs since the 1950s as a result of a steady decline in cigarette consumption and because of
technological improvements. Improvements in technology and the tobacco industry’s pursuit of
increased productivity have led to significant decreases in employment in the tobacco core sector. As
Schelling15
noted decades ago, in general, the gradual transition away from tobacco farming and
manufacturing to other economic activities would mean that today’s tobacco farmers would not lose
their jobs, but that fewer children of tobacco-farming families would become tobacco farmers
themselves. This remains true today.
Research Needs
Policymakers are sometimes reluctant to implement tobacco control measures for fear that they will
have a negative impact on employment. For this reason, high priority should be given to developing
accurate and comprehensive data on the number of people employed in both tobacco growing and
tobacco manufacturing. Studies should specify the methods used to estimate employment; for example,
to accurately measure full-time equivalent (FTE) employment in tobacco growing, it is important to
account for both seasonal and part-time work. Additional studies of the factors influencing employment
in tobacco growing and manufacturing, including the impact of technological advances and economic
globalization, as well as the potential influence of tobacco control policies, would be informative.
Studies of the effect of tobacco control policies on employment should consider the net impact of these
policies, which takes into account that losses in the tobacco sector may be offset by increases in other
sectors of goods and services.
Chapter Conclusions
1. The number of jobs that depend on tobacco—tobacco growing, manufacturing and distribution—
is low and has been falling in most countries.
2. Adoption of new production technologies and improved production techniques, together with the
shift from state to private ownership in many countries, has reduced employment in both the
tobacco-farming and -manufacturing sectors.
3. In nearly all countries, national tobacco control policies will have either no effect or a net
positive effect on overall employment because any tobacco-related job losses will be offset by
job gains in other sectors.
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4. In the few countries that depend heavily on tobacco leaf exports, global tobacco control policies
could lead to job losses, but these losses are expected to be small, gradual, and unlikely to affect
the current generation of tobacco farmers in these countries.
Chapter 16. The Impact of Tobacco Use and Tobacco Control Measures on Poverty and Development
Overview
The economic and health consequences of tobacco use are particularly pronounced among the world’s
poorest populations, who can afford these costs the least. The interrelationships of tobacco use,
individuals’ economic status, and tobacco control policies are complex and, as an integral part of a
comprehensive tobacco control strategy, require careful appraisal. With this aim in view, this chapter
examines the following topics:
The relationship between poverty and tobacco use, including implications for low- and middle-
income countries
The opportunity cost of tobacco use relative to other household expenditures, especially in poor
households
The impact of tobacco use on economic development, including population health and health
care costs
The implications of tobacco control strategies for the poor.
High-income countries have succeeded in curbing tobacco consumption by significantly raising tobacco
taxes and prices and by employing the tobacco control strategies described in the monograph. However,
today around 80% of smokers worldwide live in low- and middle-income countries, and in most
countries, regardless of country income group, tobacco use is more concentrated in low-income
populations. Understanding the effects of tobacco on low-income populations is particularly important
in reducing tobacco use and its adverse health consequences.
Chapter Summary
Tobacco use exacerbates poverty by diverting the limited resources of poor households away from basic
needs such as food and shelter, health care, and education. The opportunity costs of tobacco use are
greatest for the poor because they have the most difficulty meeting basic household needs. Increases in
health care expenditures for treatment of tobacco-related diseases and economic losses due to premature
death add additional burdens to other competing issues of the poor and of society as a whole.
An estimated 860 million adult smokers live in LMICs, and approximately 226 million globally are
living in poverty. Moreover, the economic and health burdens of tobacco use appear to be greater for
LMICs where, by definition, financial resources are more limited than in HICs. The higher
concentration of smokers who are poor in low- and lower middle-income countries indicates that the
tobacco use epidemic has not spared the poorest of the world’s poor.
Typically, a lag of a couple of decades or more occurs between the initiation of smoking at an early
age and the resulting illnesses or premature death, often in middle age. Countries at the lower end
of the world’s economic spectrum, and hence at risk of experiencing the fastest growth in tobacco
consumption in tandem with economic development, can anticipate reaching the peak effects of the
tobacco use epidemic about halfway into the 21st century. As development gradually transforms
Executive Summary
48
low-income countries into lower middle-income countries, their poorest populations will be the most
susceptible to the epidemic of tobacco use occurring in the developing world. In HICs, socioeconomic
inequality in smoking status has contributed significantly to socioeconomic inequality in health status,
an effect likely to be repeated in LMICs unless vigorous preventive actions are taken.
Curtailing tobacco use is increasingly recognized as important for global economic development. The
WHO FCTC describes “the devastating worldwide health, social, economic, and environmental
consequences” of tobacco use, and the global Sustainable Development Goals adopted in 2015 explicitly
include strengthening the implementation of the WHO FCTC as part of Sustainable Development Goal 3
(Ensure healthy lives and promote well-being for all at all ages). Already, several national development
agencies incorporate tobacco control as a development strategy. To give an example of a specific policy
goal, research showing that tobacco use crowds out expenditures on food has led to suggestions that
strategies to decrease child malnutrition should include tobacco control measures because of their
potential to increase family resources to purchase food.
Studies have assessed the implications of tobacco control measures—both tax and non-tax measures—
for reducing tobacco-related health inequities between the rich and poor. Tobacco taxes can contribute
to reducing health inequities because the poor are generally more responsive to price increases than
people who are not poor and because a portion of tax revenues can be earmarked for programs that
directly benefit the poor. Other tobacco control strategies discussed in the monograph, including public
education efforts, pictorial health warnings, advertising bans, and the provision of free or low-cost
cessation services, can also contribute to reducing tobacco use in all socioeconomic groups.
Research Needs
The complex relationships between tobacco use, poverty, and development are now well recognized.
However, evidence on how these relationships operate, especially in LMICs, is limited in several areas.
Further LMIC-based studies are needed that collect and analyze additional evidence on a wide range of
development indicators both within and between countries. Additionally, only limited evidence exists
regarding the relationships between poverty, development, and use of tobacco products other than
cigarettes. Interaction between economic development and the wider array of tobacco products used in
many LMICs should be considered, along with the impact of differences in taxation across this wider
variety of tobacco products. The literature on the equity implications of both tax and non-tax tobacco
control measures in LMICs is scant. Research to understand how both tax and non-tax measures can
contribute to reducing poverty and income inequality will help LMICs avoid repeating the experience
of HICs.
Chapter Conclusions
1. Tobacco use and its consequences have become increasingly concentrated in low- and middle-
income countries and, within most countries, among lower socioeconomic status populations.
2. Tobacco use in poor households exacerbates poverty by increasing health care costs, reducing
incomes, and decreasing productivity, as well as diverting limited family resources from basic
needs.
3. By reducing tobacco use among the poor, tobacco control policies can help break the cyclical
relationship between tobacco use and poverty.
Monograph 21: The Economics of Tobacco and Tobacco Control
49
4. Tobacco control efforts that are integrated with other public health and development policies can
improve the overall health of the poor and can help achieve the Sustainable Development Goals.
5. Lower income populations often respond more to tobacco tax and price increases than higher
income populations. As a result, significant tobacco tax and price increases can help reduce the
health disparities resulting from tobacco use.
Chapter 17. Ending the Epidemic
Overview
This summary chapter reviews the major conclusions that can be drawn from the study of the economics
of tobacco control and identifies priorities for future research in this field.
The monograph presents strong evidence that tobacco control measures are effective and do not harm
national economies. Policies and programs that reduce the demand for and supply of tobacco products
are highly cost-effective and lessen the disproportionate burden that tobacco use imposes on the poor.
Given the enormous health and economic consequences of tobacco use and the rapidly evolving global
market for tobacco, these interventions are now more urgently needed than ever, particularly in LMICs.
Research priorities (particularly in LMICs) include studies to better understand: the effects of tobacco
taxation and pricing, the economic impact of tobacco use and tobacco control measures,
interrelationships between tobacco use and poverty, illicit trade, economically viable alternatives to
tobacco growing and manufacturing, and implementation and evaluation of the World Health
Organization Framework Convention on Tobacco Control.
Implementing effective tobacco control measures makes it possible that tobacco could become a minor
public health problem rather than the public health catastrophe it currently is or could soon become in
most countries. Implementation of strong, comprehensive tobacco control strategies has reduced tobacco
use in many countries at all income levels, and government fears that tobacco control will have an
adverse economic impact are not supported by the evidence. The monograph provides the evidence that
implementing effective tobacco control measures makes sense from both an economic and public health
standpoint for countries at all income levels.
High-income countries have succeeded in curbing tobacco consumption by significantly raising tobacco
taxes and prices and by employing the tobacco control strategies described in the monograph. However,
the majority of tobacco users worldwide today live in LMICs, and in most countries tobacco use is more
concentrated in low-income populations. Understanding the effects of tobacco on low-income
populations is particularly important for reducing tobacco use and its adverse health consequences.
Executive Summary
50
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